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Rehabilitation Center Discharge Planning and Continuity of Care Audit Checklist

A comprehensive checklist for auditing discharge planning processes and continuity of care practices in rehabilitation centers to ensure smooth care transitions, reduce readmissions, and improve long-term patient outcomes.

Rehabilitation Center Discharge Planning and Continuity of Care Audit Checklist

by: audit-now
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About This Checklist

Effective discharge planning and ensuring continuity of care are critical components of successful rehabilitation outcomes. This comprehensive audit checklist is designed to evaluate and enhance the processes related to patient discharge, transition of care, and follow-up support in rehabilitation centers. By focusing on key areas such as discharge assessment, patient education, care coordination, and post-discharge follow-up, this checklist helps rehabilitation centers improve patient outcomes, reduce readmission rates, and ensure seamless transitions across the care continuum.

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Industry

Healthcare

Standard

CMS Discharge Planning Standards

Workspaces

Healthcare Centers

Occupations

Case Managers
Social Workers
Rehabilitation Therapists
Nurses
Physicians
Quality Improvement Coordinators
Healthcare Administrators
Patient Advocates
1
Is the care transition documentation completed and compliant with CMS standards?
2
How many post-discharge follow-up calls were made within 72 hours of discharge?
Min: 0
Target: 3
Max: 10
3
How effective was patient education provided during discharge planning?
4
Was there effective interdisciplinary communication during the discharge planning process?
5
Was a readmission risk assessment performed prior to discharge?
6
List the community resources utilized for patient follow-up.
7
What was the discharge date for the patient?
8
Describe the post-discharge care plan that was communicated to the patient.
9
How engaged was the patient during the discharge planning process?
10
Were educational materials provided to the patient upon discharge?
11
How many questions did the patient ask during the discharge planning?
Min: 0
Target: 2
Max: 15
12
Provide the follow-up contact information given to the patient.
13
Was an interdisciplinary team meeting held to discuss the patient's discharge plan?
14
Provide a summary of the care transition plan discussed with the patient.
15
How many referrals were made to community resources or services post-discharge?
Min: 0
Target: 2
Max: 10
16
What is the date of the follow-up appointment scheduled for the patient?
17
Was a medication reconciliation performed before discharge?
18
How many patient safety incidents were reported during the patient's stay?
Min: 0
Target: 0
Max: 20
19
How satisfied was the patient with the discharge process?
20
Describe any quality improvement actions taken as a result of patient feedback during their stay.

FAQs

Discharge planning and continuity of care audits should be conducted quarterly, with ongoing monitoring of key performance indicators. A comprehensive annual review is also recommended to identify long-term trends and areas for improvement.

Key components include assessment of discharge readiness criteria, evaluation of patient and family education processes, review of care transition documentation, analysis of post-discharge follow-up procedures, examination of interdisciplinary team communication, and assessment of community resource utilization for ongoing patient support.

The audit team should include case managers, social workers, rehabilitation therapists, nurses, physicians, quality improvement coordinators, and representatives from partner healthcare facilities or community services. Patient advocates or former patients may also provide valuable input.

Audit results can be used to identify gaps in the discharge process, enhance patient education materials, improve care coordination protocols, develop more effective follow-up strategies, strengthen partnerships with community resources, and implement targeted interventions to reduce readmission rates and improve long-term patient outcomes.

Technology, such as electronic health records (EHRs) and care coordination platforms, plays a crucial role in facilitating smooth care transitions. Audits should evaluate the effectiveness of these systems in supporting discharge planning, ensuring accurate information transfer, facilitating communication between providers, and enabling post-discharge monitoring and follow-up.

Benefits of Rehabilitation Center Discharge Planning and Continuity of Care Audit Checklist

Reduces hospital readmission rates

Improves patient satisfaction and outcomes

Enhances coordination between healthcare providers

Ensures compliance with discharge planning regulations

Optimizes resource utilization and reduces healthcare costs