General Nursing (RGN)
Discharge Planning
A coordinated process of assessing and arranging the patient's ongoing care, support, education, referrals and follow-up needs in preparation for discharge.
Purpose
- Promote continuity of care after discharge.
- Identify ongoing patient and caregiver needs.
- Prepare the patient and family for safe care at home.
- Coordinate multidisciplinary and community services.
- Reduce avoidable complications and readmissions.
Indications
- Patient admitted to hospital and likely to require discharge planning.
- Patient with ongoing care needs after discharge.
- Patient requiring community services, equipment or follow-up.
Equipment
- Patient's medical records (Manual or electronic)
- Discharge planning form/checklist (Manual or electronic)
- Referral forms (if applicable)
Procedure steps
- Begin discharge planning early, preferably on admission.
- Assess patient's ongoing care needs post-discharge.
- Identify patient's home and social support systems.
- Involve patient and family in the planning process.
- Liaise with the multidisciplinary team (physiotherapist, dietitian, social worker etc.) as needed.
- Assess patient's and caregiver's ability to manage care at home.
- Identify any equipment or home modifications needed.
- Arrange for necessary referrals to community health services if required.
- Plan for follow-up appointments and reviews.
- Educate patient and family on condition, medication and home care.
- Assess patient's understanding of the discharge plan.
- Document the discharge plan in patient's notes.
- Communicate discharge plan to all members of the healthcare team.
- Review and update discharge plan as patient's condition changes.
- Confirm readiness for discharge with the medical team.
Precautions
- Begin planning early.
- Involve the patient and appropriate family members.
- Assess caregiver ability to provide care safely.
- Confirm necessary referrals and follow-up arrangements.
- Communicate the plan to the healthcare team.
- Update the plan when the patient's condition changes.
Educational resource only. Follow current Nursing and Midwifery Council guidance, local institutional protocols, scope of practice, and clinical supervision.
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