MDS Alert

Don't forget to include advance directives.

If you're in the market for a "to do" list for discharge, check out the MDS 3.0 RAI User's Manual instructions for Section Q. According to the manual, discharge instructions should include at a minimum:

-- "the individual's preferences and needs for care and supports; personal identification and contact information, including Advance Directives; provider contact information of primary care physician, pharmacy, and community care agency including personal care services (if applicable) etc.; brief medical history; current medications, treatments, therapies, and allergies; arrangements for durable medical equipment; arrangements for housing; and contact information at the nursing home if a problem arises during discharge.

-- A follow-up appointment with the designated primary care provider in the community and other specialists (as appropriate).

-- Medication education.

-- Prevention and disease management education, focusing especially on warning symptoms for when to call the doctor.

-- Who to call in case of an emergency or if symptoms of decline occur."

The manual also directs the facility to "involve community mental health resources (as appropriate) to ensure that the resident has support and active coping skills that will help him or her to readjust to community living."

Staff should also use "teachback methods" to ensure the resident comprehends "all of the factors associated with his or her discharge," states the MDS 3.0 RAI User's Manual.