CHS122 Prepare a discharge plan with individuals

Overview

This standard covers the preparation of a discharge plan with individuals to ensure that their post-discharge health and care is optimised and stabilisation and improvement of their condition is planned. It includes the discharge of individuals from the emergency, urgent or scheduled care service.  Individuals may be discharged into the care of other health and care providers, their own care, or that of significant others. Users of this standard will need to ensure that practice reflects up to date information and policies. Version No 1

Knowledge and Understanding

You will need to know and understand:

1. The current European, national land local legislation, guidelines, policies and protocols which affect your responsibilities and work practice
2. The policies and guidance which clarify your scope of practice and the relationship between yourself and other members of staff in terms of delegation and supervision
3. The importance of confidentiality and how to ensure personal data is kept confidential whilst being shared with other health and care providers
4. Your role and the importance of working within your own scope of practice
5. The roles and responsibilities of other team members
6. The different requirements health and care providers must meet to support an individual’s personal and socio-cultural needs
7. The importance of keeping the individual informed about what you are doing and any relevant aspects involved in the development of the discharge plan
8. The importance of considering the individual’s communication difficulties/differences and level of knowledge in answering questions about the discharge process
9. The range of motivations people may have for changing their behaviour and lifestyle, and how to discover their motivations
10. The range of services provided locally by other health and care providers, including palliative and end of life care services, and how to access these services
11. The range of services and support groups available locally and nationally for people who need information and support in making and maintain changes in their behaviour, and how to access these services
12. The multi-disciplinary team member responsible for each aspect of the individuals’ care plan, and how to appropriately contact them
13. The arrangements, procedures and protocols for the discharge process
14. The bio-psycho-social model of health
15. The criteria for prescribing suitable medications according to national guidelines (e.g. NICE guidelines, SIGN guidelines)
16. The types and methods of taking different medications
17. The effects, side-effects and potential interactions of different medications and how these should be accounted for in the discharge plan
18. The importance of recording information clearly, accurately and in a systematic manner
19. The types of information that must be recorded in relation to different aspects of the discharge plan
20. The importance of recording information in the appropriate manner for the discharge being planned

Performance Criteria

You must be able to do the following:

1. review all progress reports and interpret the results of observations, tests, assessments and interventions
2. review the individual’s medication, including the need for changes and possible side effects
3. identify and take full account of the individual’s risk assessment when planning the discharge
4. evaluate the effectiveness of health and care providers in addressing the individual’s needs and meeting prior agreed goals
5. renegotiate care plans to optimise stabilisation and improvement in the individual’s condition
6. communicate appropriately with other health and care providers during and following discharge regarding the individual’s progress, changes in the care plan, and details of discharge
7. provide post discharge information and support to the individual and significant others
8. identify the individual’s discharge destination and assess the  available resources in line with the individual’s needs
9. organise any necessary medications, rehabilitation and mobility aids and adaptations, in collaboration with the individual and significant others
10. arrange any required follow up arrangements with the individual, including out-patient appointments and home visits
11. Identify any reasons for delays and initiate actions to resolve them
12. maintain timely, accurate, complete and legible records
13. work at all times within appropriate patient and information confidentiality guidelines and protocols

Additional Information

This National Occupational Standard was developed by Skills for Health. This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004): Dimension: HWB6 Assessment and treatment planning This standard has replaced EUSC_10