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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
4.5

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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?

Select compliance status.

To ensure that all necessary documentation is in place for effective care transitions and compliance with regulations.
2
How many post-discharge follow-up calls were made within 72 hours of discharge?

Enter the number of follow-up calls.

To assess the level of follow-up care provided to patients post-discharge.
Min: 0
Target: 3
Max: 10
3
How effective was patient education provided during discharge planning?

Select the effectiveness level.

To evaluate the effectiveness of patient education in ensuring understanding of post-discharge care.
4
Was there effective interdisciplinary communication during the discharge planning process?

Indicate whether communication was effective.

To ensure that all team members are informed and contributing to the discharge plan.
5
Was a readmission risk assessment performed prior to discharge?

Select the assessment status.

To identify patients at high risk of readmission and ensure appropriate follow-up measures are in place.
6
List the community resources utilized for patient follow-up.

Provide details of community resources utilized.

To ensure patients have access to necessary community resources post-discharge.
7
What was the discharge date for the patient?

Enter the patient's discharge date.

To track the timing of discharge for follow-up and readmission analysis.
8
Describe the post-discharge care plan that was communicated to the patient.

Provide a detailed description of the post-discharge care plan.

To ensure the patient understands their care plan and any required follow-up actions.
9
How engaged was the patient during the discharge planning process?

Select the level of patient engagement.

To evaluate the patient's involvement in their own care and discharge planning.
10
Were educational materials provided to the patient upon discharge?

Indicate if educational materials were provided.

To ensure that patients have access to information regarding their care post-discharge.
11
How many questions did the patient ask during the discharge planning?

Enter the number of questions asked by the patient.

To assess the patient's understanding and concerns regarding their post-discharge care.
Min: 0
Target: 2
Max: 15
12
Provide the follow-up contact information given to the patient.

Enter the follow-up contact details.

To ensure patients know whom to contact for questions or concerns after discharge.
13
Was an interdisciplinary team meeting held to discuss the patient's discharge plan?

Select the meeting status.

To confirm that all relevant healthcare providers are aligned in the discharge planning process.
14
Provide a summary of the care transition plan discussed with the patient.

Summarize the care transition plan.

To ensure that the patient understands their care transition and the steps involved.
15
How many referrals were made to community resources or services post-discharge?

Enter the number of referrals made.

To evaluate the extent of referrals that facilitate the patient's recovery.
Min: 0
Target: 2
Max: 10
16
What is the date of the follow-up appointment scheduled for the patient?

Enter the scheduled follow-up appointment date.

To track the patient's follow-up care and ensure timely interventions.
17
Was a medication reconciliation performed before discharge?

Indicate if medication reconciliation was completed.

To ensure that all medications are accurately documented and any discrepancies are resolved, reducing the risk of adverse drug events.
18
How many patient safety incidents were reported during the patient's stay?

Enter the number of reported safety incidents.

To assess the safety of the care environment and identify areas for improvement.
Min: 0
Target: 0
Max: 20
19
How satisfied was the patient with the discharge process?

Select the satisfaction level.

To evaluate the effectiveness of the discharge process from the patient's perspective.
20
Describe any quality improvement actions taken as a result of patient feedback during their stay.

Provide details of any quality improvement actions.

To document steps taken to enhance patient care based on feedback and improve future discharge processes.

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

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