Standard 3.6 Discharge and patient follow-up.

 Standard 3.6 Discharge and patient follow-up.

Discharge and follow-up of patients is carried out according to established procedures.

Discharge and follow-up of patients is carried out according to appropriate procedures. If a patient requires a referral to another health facility, the referral is made according to the patient's needs and condition to another service facility regulated by clear policies and procedures.

a. Criterion 3.6.1

Discharge and patient follow-up aimed at continuity of care are guided by standard procedures.

1) Main Thoughts

a) To ensure continuity of service, it is necessary to establish policies and procedures for patient discharge and follow-up.

b) The doctor/dentist together with other health workers prepares a discharge plan together with the patient/patient's family. The discharge plan contains instructions and/or support that need to be provided by both the Community Health Center and the patient's family at the time of discharge or follow-up at home, according to the results of the study carried out.

c) Discharge of patients is carried out based on criteria set by the doctor/dentist responsible for the patient to ensure that the patient's condition is suitable for discharge and will receive follow-up services after discharge, for example outpatients who do not require inpatient treatment, inpatients no longer require inpatient treatment at the Community Health Center, patients who because of their condition require referral to FKRTL, patients who because of their condition can be treated at home or in a nursing home, patients who refuse inpatient treatment, patients/patients' families who request to go home at their own request.

d) Discharge patient resume provides an overview of the patient during hospitalization. This resume contains:

(1) medical history, physical examination results, diagnostic examinations;

(2) inpatient indication, diagnosis, and other comorbidities;

(3) procedures and therapies that have been provided;

(4) medication that has been given and medication for discharge;

(5) patient's health condition; And

(6) follow-up instructions and explanations to patients, including contact numbers that can be contacted in emergency situations.

f) Information about the resume of discharged patients which is given to the patient/patient's family at the time of discharge or referral to another health facility is necessary so that the patient/patient's family understands the follow-up actions that need to be taken to achieve optimal service results.

g) The patient's medical resume consists of at least:

(1) Patient identity;

(2) admission diagnosis and indication of patient treatment;

(3) summary of the results of physical and supporting examinations, final diagnosis, treatment, and health service follow-up plans; And

(4) the name and signature of the doctor or dentist providing health services.

h) The medical resume given to the patient upon discharge from hospitalization consists of:

(1) general patient data;

(2) anamnesis (history of disease and treatment);

(3) inspection; And

(4) therapy, actions and/or recommendations.

2) Assessment Elements:

a) Doctors/dentists, nurses/midwives, and other care providers carry out discharge, referral, and follow-up care in accordance with the plan prepared and discharge criteria (R,D).

b) Medical resumes are provided to patients and interested parties upon discharge or referral (D,O,W).