Discharge , referral and death summary

Discharge Certificate , Referral form and Death Summary

1. Discharge, Referral and Death certificate P resented by : Dr Mubashir Moderator : Dr Mohsin Dept. of General Surgery HIMSR & HAHC Hospital

2. DISCHARGE SUMMARY As per NABH, “Discharge is a process by which a patient is shifted out from the hospital with all concerned medical summaries ensuring stability. The discharge process is deemed to have started when the consultant formally approves discharge and ends with the patient leaving the clinical unit” NABH has set a standard of 180 minutes for the completion of discharge process.

3. Steps of discharge process Doctor plans a discharge on round and writes it on case file. Patients/relatives are informed by doctor/staff nurse regarding a discharge. Resident doctor prepares a discharge and hands over to staff nurse. Patient’s relatives sent to cash counter for final bill settlement. Patient’s relatives hand over the bill settlement to ward staff nurse. Staff nurse after checking the bill settlement and hands over discharge summary coupled with counselling by concerned resident doctor. Patient send off.

4. According to NABH standard (AAC.13) Documented discharge process. Objective elements: The patient’s discharge process is planned in consultation with the patient and /or family. Documented procedures exist for coordination of various departments and agencies involved in the discharge process (including medicolegal and absconded cases).

5. 3. Documented policies and procedures are in place for patients leaving against medical advice (LAMA) and patient being discharged on request (DOPR). 4. A discharge summary is given to all the patients leaving the organisation (including patients leaving against medical advice and on request). 5. The organisation defines the time taken for discharge and monitors the same.

6. NABH standard (AAC.14.) Content of discharge summary Objective elements: Discharge summary is provided to patients at the time of discharge. Discharge summary contains patients Name, unique identification number, date of admission and date of discharge. Discharge summary contains the reasons for admission, significant findings and patients condition at the time of discharge.

7. 4. Discharge summary contains information regarding investigation results, any procedure performed, medication administered and other treatment given. 5. Discharge summary contains follow up advice, medication and other instructions in an understandable manner. 6. Discharge summary incorporates instructions about when and how to obtain urgent care. 7. In case of death, the summary of the case also includes the cause of death.

8. Referral of a patient According to WHO ‘’A referral is a process in which a health worker at one level of health system, having insufficient resources (drugs, equipment, skills) to manage a clinical condition, seeks the help of a better or differently resourced facility at the same or higher level to assist in”.

9. Types General physician to a specialist. From one specialist to another. From one hospital to another.

10. Common reasons for referral (either emergency or routine cases) are: For taking expert opinion for the patient. For seeking better treatment of the patient. For use of high end diagnostic and therapeutic tools, which is not available at current level.

11. Referral system plays a vital role in management of diseases in any health care system. This system is pyramidical. Sub center and Primary health care center constitute the base. Secondary centers are in middle which include community health centers and district hospitals. Tertiary centers are at top which include medical college hospitals and super speciality hospitals.

12. SUB CENTER PRIMARY HEALTH CENTER COMMUNITY HEALTH CENTER SUB DISTRICT HOSPITAL DISTRICT HOSPITAL TERTIARY HEALTH FACILITIES IN MEDICAL COLLEGE HOSPITALS SUPER SPECIALITY HOSPITALS

13. Death certificate It is a document issued by the government (Registrar, Birth and death) to the kin of deceased, stating the date, fact and cause of death. It is a valuable source for state based and national mortality statistics. It is required to establish the fact of death legally, for relieving the deceased from social, legal and moral obligations. Also used to enable settlement of property inheritance, and to authorise the family to collect insurance and other benefits.

14. Medical certificate of cause of death (MCCD) Certificate issued by a doctor after patient has died. Primarily, It details the cause of death but also often includes date, time and place of death. It is required to register a death with local authorities.

15. Guidelines for issuing MCCD Issued immediately after patient is declared dead by the same doctor and if it is a natural death. It should reach the registrar birth & death within 14 days. No fees to be charged. Issued even if his dues are not cleared by the relatives.

16. MCCD should not be issued and dead body not released if : Injured is brought dead. Crime has already been registered by the police. Cause of death is not known.

17. Typically it has 2 parts Upper part : Particulars of the deceased along with medical data in respect to the disease causing death. Lower part: Particulars of the deceased along with the date, time and place of occurrance of death . Handed over to relatives.