Once you leave hospital, it is important you continue to get the right healthcare and support from the right people. Discharge planning aims to make sure this happens. It is the link between the treatment you had in hospital and the care you will need in the community once discharged.

What is hospital discharge planning?

Discharge planning is the development of a personalised plan to ensure the smooth transition of a patient from a health organisation such as a hospital to wherever the patient is going next — it might be home, residential care, respite care, palliative care or somewhere else.

Good discharge planning can avoid complications after discharge from hospital, avoid errors with medications and may help prevent a person from being readmitted to hospital later on.

Who is involved in hospital discharge planning?

Discharge planning should involve the patient, carer, family and any staff involved in the patient’s care. Usually there will be one person, such as a discharge planner, who coordinates the process.

What is included in hospital discharge planning?

Discharge planning involves taking into account things like:

• follow-up tests and appointments
• whether you live alone
• whether someone can help you when you go home
• your mobility
• equipment needed for your recovery
• wound care, if needed
• medicines, especially if you need multiple medications
• dietary needs
• rehabilitation
• whether there will be any restrictions on you once discharged, for example driving or lifting

Discharge planning should ensure that all the services you need to support you once you leave hospital are in place.

This might include things like community support with medications, dressings, food or cleaning. It might include aids and appliances to help you stay in your own home, independently.

In some cases, it is simple. For example, you might be expected to leave hospital in 2 days with certain medications, and you might be told to see your GP 2 days after you get home.

But if you have a chronic disease or need plenty of ongoing care, it could be more complex. It might involve you, your GP, other healthcare professionals, family members and carers.

All of these people should have a copy of the discharge plan, so that everyone knows what they need to do to ensure that you have continuing care.

Where appropriate, other people or organisations should have a copy too. These could include a residential care facility, rehabilitation services or community services.

When is hospital discharge planning done?

Ideally, discharge planning starts as soon as you are admitted to hospital. And ideally, it also involves you and your family, as well as hospital staff. If you are going in for elective surgery, the discharge planning may occur before you go into hospital — so appropriate care can be organised in advance for when you get out.

What is a hospital discharge summary?

A discharge summary is one part of a discharge plan. It is a document prepared while you are in hospital, usually by your hospital doctor. It is generally an electronic document, known as an electronic discharge summary (eDS).

The hospital should send it to other healthcare professionals involved in your care, such as your GP or sometimes a pharmacist or carer.

It is important your GP gets a copy of this document so that they know why you were admitted to hospital, what care you received and how to continue to care for you.

A copy of the electronic discharge summary will also be added to your ‘my Health Record, unless you have opted out of having one. You may also be given a paper copy of the summary when you leave hospital.

The discharge summary will explain:

• why you were admitted to hospital
• the main diagnosis
• which tests were performed
• what care you received
• which medications you are taking on discharge from hospital, and possibly which medications you have taken in the past
• which other medications you have taken in the past
• which medical or surgical procedures were performed
• whether you had any allergies or bad reactions
• a clinical summary of your situation now and follow-up actions
• which future services have been arranged, such as community services
• any follow-up appointments that have been made

Tips for a safe hospital discharge

Here are some questions you could ask yourself before you are discharged from hospital:

• Do I understand what happened in hospital?
• Do I understand which treatment I need now — and in the future?
• Do I know which medications to take and when? Do I have enough of those medications until I can see my GP?
• Do I need to make any dietary changes? Will I be able to shop for food and manage to feed myself?
• Do I know when my follow-up appointments are?
• Has my GP been informed of my admission and of my discharge plan?
• Do I need care from family members? If so, has there been a family meeting? Does everyone understand their roles and responsibilities?
• Do I have transport arranged?
• Am I allowed to drive once discharged?
• Do I have an estimate of recovery time or time for any wounds to heal?
• Are there any concerns or questions I should raise before I am discharged from hospital?

If you can’t answer those questions, please ask your hospital doctors and nurses for more information. It is their responsibility to make sure you have it all. If you still don’t have everything you need, ask for a nursing supervisor.

More information

Find a healthcare service with healthdirect’s Service Finder tool or call 1800 022 222 (known as NURSE-ON-CALL in Victoria) for 24-hour health advice and information.