Discharge instructions

A patient should have a personalised care plan when they leave hospital. Planning a patient’s discharge starts in the preoperative stage of their journey.

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Discharge planning is a multidisciplinary team effort and includes shared decision making with a patient and their family or carer.1, 2

When developing discharge instructions, consider:

  • how ready a patient is for discharge3
  • any extra supports they may need once discharged, e.g. assistance with cooking and cleaning, assistive technology and equipment, ongoing wound care2, 4
  • their postoperative goals
  • their living arrangements, as these can impact their postoperative recovery. For instance, a patient may live in a rural or remote area, they may be living alone or have primary carer responsibilities.4

Provide a discharge summary to the primary care provider or a patient’s general practitioner, including:

  • diagnosis
  • operation details, e.g. type of surgery, date
  • complications
  • active medical problems
  • pain management
  • changes to medication
  • post-discharge instructions, e.g. wound care, mobilisation, nutrition, driving restrictions
  • blood and other test results
  • contact details for escalation of care, e.g. general practitioner liaison service, if available.1

If relevant, include medical device information in the discharge summary and upload this to My Health Record.

Discharge education can influence a patient’s participation in self-care post discharge.3 A patient needs to:

  • understand what is in their discharge summary
  • be given verbal and written information about their postoperative recovery
  • be given contact details for escalation of care and any follow-up requirements.1

Consider different levels of health literacy and vulnerable patient cohorts requiring supports and adjustments.

Virtual care can support discharge planning, e.g. in-home assessments, and transfer from metropolitan to regional sites.

    Resources

    Care Transitions from Hospital to Home: IDEAL Discharge Planning
    An overview of the key elements for engaging the patient and family in discharge planning.
    Source: Agency for Healthcare Research and Quality

    Comprehensive Care Standard: Transition of Care – Discharge From an Acute Facility
    A fact sheet of information for clinicians to consider when planning for patient discharge.
    Source: Australian Commission on Safety and Quality in Health Care

    Re-Engineered Discharge (RED) Toolkit
    A toolkit for hospitals to improve discharge processes to reduce readmissions.
    Source: Agency for Healthcare Research and Quality

    References

    1. Bougeard AM, Watkins B. Transitions of care in the perioperative period - a review. Clin Med (Lond). Nov 2019;19(6):446-9. DOI: 10.7861/clinmed.2019.0235
    2. National Safety and Quality Health Service (NSQHS) Standards. Comprehensive care standard: Transition of care - discharge from an acute facility. Sydney, Australia: ACSQHC; 2020 [cited 28 Mar 2024].
    3. Kang E, Gillespie BM, Tobiano G, et al. Discharge education delivered to general surgical patients in their management of recovery post discharge: A systematic mixed studies review. Int J Nurs Stud. Nov 2018;87:1-13. DOI
    4. South Australia Health. Pre-operative assessment of booked adult elective surgery. SA, Australia: Government of South Australia; 6 Aug 2018 [cited 28 Mar 2024].
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