Discharging: medications, diet, etc.

  • Medication reconciliation: this is perhaps the single most important part of the patients discharge, and probably their entire hospitalization. Again, your senior will go over this with you on every patient discharge.
    -Diabetes medications. These can be tricky. Often we will place patients on a subcutaneous insulin regimen while they are inpatient. If they have been uncontrolled their oral medication doses might need to be increased, or their insulin regimen might need to be increased. This is very specific to every patient and too detailed to completely cover in this guide.
    -HTN medications: Same principle applies as for DM meds. If they have been running hypertensive during their admission, they will need their medications titrated on discharge.
    -Antibiotics/antifungals: special attention should be payed to the duration of antibiotics prescribed on discharge. If patients require IV antibiotics for a long duration (for osteomyelitis, endocarditis etc), they will require insertion of a PICC line at some point during their hospitalization. Always be aware of possible drug interactions when prescribing known CYP inhibitors such as fluconazole to patients on high risk medications such as Coumadin, flecainide etc.
  • Diet: if patient had a speech evaluation inpatient, OR were seen by GI with recommendations for a specific diet, be sure to mention that in the discharge orders and in the discharge summary. For example: patient was admitted with dysphagia, had an endoscopy procedure and recommendations from GI were to continue mechanically soft diet with crushed medicines. This will require a specific ‘mechanically soft diet’ on discharge and a special comment to crush all medicines.
  • Follow ups: general rule of thumb is, unless otherwise specified, one week follow up with their PCP (primary care physician) and two week follow up with a specialist that was consulted on the case, unless not required (cardiology, nephrology, pulmonary etc).
    **Review IMAGES (CT scans, xrays) before the patient is discharged. Often incidentally discovered nodules/cysts are seen on scans and mentioned by the radiologist to be followed on. For example: you order a CT scan to evaluate a patients persistent pleural effusion. Incidentally noted is a 1.5cm lung nodule which requires repeat evaluation in three months. You should mention this in your discharge summary to be followed by the primary care physician.
  • Common special discharge scenarios:
    – Hip fracture patients, s/p surgery: These patients will require DVT prophylaxis anticoagulation on discharge. Usually this is prophylactic lovenox or xarelto for several weeks and is usually specified by the orthopedic physicians on the case.
    – Osteomyelitis: if these patients are being discharged with IV antibiotics, they will often require weekly ESR, CRP, CBC, CMP drawn, with results to be followed by infectious disease or primary care physicians.
    -Patients with DVT/PE/atrial fibrillation: Make sure Coumadin is prescribed on discharge, and the patient has enough refills. Coumadin and INR checks. Usually the patient will require INR check roughly 3 days after discharge, with results to the patients PCP.
    -Patients with labs ordered that have not resulted yet: For example you have ordered workup for pheochromocytoma with some labs still pending when patient was discharged from the hospital. Mention these specifically in your discharge summary, with results to be followed the patient’s primary care physician and/or a specialist that was following them in the hospital.
  • Where is the patient going after this admission?
    -Usually, if the patient is fairly active they are likely going home. However, you will often see patients who are fairly fragile and weak. We consult physical therapy inpatient
    Physical therapy will assess the patient for overall functional status and can recommend any of the following: SNF (skilled nursing facility), inpatient rehab, outpatient rehab, home.
    TIP: Discharges to SNF or inpatient rehab might require additional paperwork when discharging the patients from JCMC and the VA.
  • Home health is a service where medical professionals go to the patient’s home to draw labs, and can also administer medications. This is useful for patient who will require drawing of frequent labs after discharge, for ex: INR check 3 days after discharge, ESR/CRP for osteomyelitis etc. This is very easy to arrange on discharge through the EHR through a simple order when discharging the patient.

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