Client is a new admission with discharge potential. Stay projected to be of short duration, and client plans d/c to: [__] Home [__] Assisted Living

Description
Record Id: 280 Code: 00280
The client, a recent ... Please Login or Join to access this information
References
Diane Carter & LeeAnna Spiva. (2017). A comprehensive discharge planning process: Relevance and value. Nursing Clinics, 52(3), 359-367. https://doi.org/10.1016/j.cnur.2017.04.001
S. Appel, E. Gil, G. Warshaw, & E. Snow. (2021). Transitional Care for Older Adults: A Research Agenda. The Gerontologist, 61(4), 514–522. https://doi.org/10.1093/geront/gnaa186
icon-outcomeOutcomes
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Record Id: 1554Will successfully transition from ... Please Login or Join to access this information
Description Client will smoothly ... Please Login or Join to access this information
Suggested days to Evaluation: 90
Rationale This nursing outcome ... Please Login or Join to access this information
Suggested Evaluation Date: 07/15/2026
Outcome References
Hirschman, K. B., Shaid, E., McCauley, K., Pauly, M. V., & Naylor, M. D. (2019). Continuity of Care: The Transitional Care Model. Online Journal of Issues in Nursing, 24(3). https://doi.org/10.3912/OJIN.Vol24No03PPT54
Altfeld, S.J., Shier, G.E., Rooney, M., Johnson, T.J., Golden, R.L., Karavolos, K., Avery, E., Nandi, V., & Perry, A.J. (2018). Effects of an Enhanced Discharge Planning Intervention for Hospitalized Older Adults: A Randomized Trial. Gerontologist, 58(4), 670–679. https://doi.org/10.1093/geront/gnw202
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Record Id: 2215Nursing, social services and ... Please Login or Join to access this information
Description Weekly review and ... Please Login or Join to access this information
Rationale Regular meetings ensure ... Please Login or Join to access this information
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Record Id: 2216SW to visit weekly ... Please Login or Join to access this information
Description A weekly visit ... Please Login or Join to access this information
Rationale Weekly SW visits ... Please Login or Join to access this information
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Record Id: 2217Encourage client and family ... Please Login or Join to access this information
Description Promotes active participation ... Please Login or Join to access this information
Rationale Involving clients and ... Please Login or Join to access this information
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Record Id: 2218SW to contact preferred ... Please Login or Join to access this information
Description The social worker ... Please Login or Join to access this information
Rationale The Social Worker ... Please Login or Join to access this information
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Record Id: 2219Make referrals to other ... Please Login or Join to access this information
Description This involves the ... Please Login or Join to access this information
Rationale Referring to other ... Please Login or Join to access this information
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Record Id: 2220Discuss with rehab any ... Please Login or Join to access this information
Description Engages in dialogue ... Please Login or Join to access this information
Rationale Ensuring special equipment ... Please Login or Join to access this information
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Record Id: 2222Notify MD of discharge ... Please Login or Join to access this information
Description Involves prompt communication ... Please Login or Join to access this information
Rationale Quickly informing doctors ... Please Login or Join to access this information
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Record Id: 2223Assure client/family of facility’s ... Please Login or Join to access this information
Description Involves reassuring the ... Please Login or Join to access this information
Rationale To maintain trust ... Please Login or Join to access this information