Home Health & Hospice Week

To get an idea of what may be on your plate, take a look at the proposed 22 items required for home health agency discharge and transfer summaries:

• Demographic information, including but not limited to name, sex, date of birth, race, ethnicity, and preferred language;
• Contact information for the physician responsible for the home health plan of care;
• Advance directive, if applicable;
• Course of illness/treatment;
• Procedures;
• Diagnoses;
• Laboratory tests and the results of pertinent laboratory and other diagnostic testing;
• Consultation results;
• Functional status assessment;
• Psychosocial assessment, including cognitive status;
• Social supports;
• Behavioral health issues;
• Reconciliation of all discharge medications (both prescribed and over-the-counter);
• All known allergies, including medication allergies;
• Immunizations;
• Smoking status;
• Vital signs;
• Unique device identifier(s) for a patient’s implantable device(s), if any;
• Recommendations, instructions, or precautions for ongoing care, as appropriate;
• Patient’s goals and treatment preferences;
• The patient’s current plan of care, including goals, instructions, and the latest physician orders; and
• Any other information necessary to ensure a safe and effective transition of care that supports the post-discharge goals for the patient.

Source: Nov. 3, 2015 Federal Register, Proposed Rule: Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies, www.gpo.gov/fdsys/pkg/FR-2015-11-03/pdf/2015-27840.pdf.