Document name:
Discharge and Clinical Handover of
service users/Patients (including leave of
absence for informal service users)
Document type:
Policy
Staff group to whom it
applies:
All South West Yorkshire Partnership
NHS Foundation Trust services
Distribution:
The whole of the Trust
How to access:
Intranet and internet
Issue date:
October 2012
Next review:
October 2014
Approved by:
Executive Management Team
Version:
3.1
Developed by:
Phil Tordoff – CPA Lead
Julie Fleetwood – Assistant Director
Director leads:
Director of Nursing, Clinical Governance
and Safety
Director of Nursing, Clinical Governance
and Safety
Contact for advice:
Contents
1.
2.
3.
4.
5.
Introduction ........................................................................................................... 1
Purpose and Scope of the policy ........................................................................ 1
Definitions.............................................................................................................. 4
Duties and Responsibilities ................................................................................. 6
Principles ............................................................................................................... 7
5.1
Discharge and clinical handover of care ...................................................... 8
5.2
Discharge and clinical handover of care to other health care
Establishments ............................................................................................. 8
5.3
Transfer requirements of all services.............................................................. 9
5.4
Transport from in-patient services...................................................................10
5.5
Out of hours discharges and clinical handover of care...................................11
5.6
Planned discharge ....................................................................................... 12
5.7
Transfer to acute services ............................................................................ 13
5.8
Disengagement from services...................................................................... 13
5.9
Outcomes of assessments ........................................................................... 14
5.10 Principles of good practice .......................................................................... 14
5.10.1 48 hour follow-up from hospital charge ............................................. 16
5.10.2 7 day follow-up .................................................................................. 16
5.10.3 Implementation of 7 day follow-up. ...................................................... 17
5.11 Continuing care. .......................................................................................... 17
5.12 Medication management ............................................................................. 18
5.13 Mental Health Act (1983) Section 117 – Mental Health ............................... 19
5.14 Supervised community treatment................................................................. 19
5.15 Discharge against medical advice................................................................ 20
5.15.1 Discharge against medical advice (non mental health)......................... 20
5.16 Leave of Absence ........................................................................................ 21
5.17 Communication with the General Practitioner .............................................. 22
5.18 Specific responsibilities in discharge arrangements from inpatient
Services........................................................................................................ 23
5.18.1 Role of consultant/Responsible Clinician ........................................ 23
5.18.2 Role of Clinical Team manager/ward manager/unit manager......... 24
5.18.3 Role of nurse in charge of the in-patient facility at the time of
discharge......................................................................................... 24
5.18.4 Role of named nurse/Professional .................................................. 24
5.18.5 Role of care co-ordinator (mental health)........................................ 25
5.18.6 Role of Allied Health Professionals ................................................. 25
5.18.7 Role of Social services .................................................................... 26
5.18.8 Role of community teams ............................................................... 26
5.18.9 Specific responsibilities in non-in-patient areas .............................. 27
5.19 Documentation upon discharge............................ ........................................ 27
5.17
6.
7.
8.
9.
5.19.1 Information to the service user .......................................................... 27
5.19.2 Letter to GP ....................................................................................... 28
Electronic records – RiO and SYSTMONE .................................................. 28
Equality Impact Assessment ................................................................... 29
Dissemination and Implementation arrangements................................ 31
7.1 Dissemination......................................................................................... 31
7.2 implementation of Policy ........................................................................ 31
7.3 Training .................................................................................................. 31
Monitoring compliance ............................................................................. 31
References....................................................................................................32
Appendices:
Appendix 1 The Care Programme Approach………………………………………… … 33
Appendix 2 Checklist for the Review and Approval of Procedural Document……….. .34
Appendix 3 Discharge from In-Patient Care Against Medical Device........................... 36
Appendix 4 Examples of Discharge Checklist and discharge summaries
/forms ...................................................................................................... 37
Appendix 5 Discharge Medication Summary................................................................ 41
Appendix 6 Client Transfer Information (RiO)............................................................... 42
Appendix 7 Discharge letter generated from RiO ......................................................... 43
Appendix 8 Mount Vernon local work instruction – Discharge of a patient.....................45
Appendix 9 Mount Vernon local work instruction – Transfer of a patient to
any other hospital......................................................................................... 50
Appendix 10 Version Control Sheet ............................................................................. 52
1.
Introduction
This policy applies to all persons who are discharged from South West
Yorkshire Partnership NHS Foundation Trust services or have a clinical
handover of care within or external to Trust services
This policy applies to discharge from Trust services generally and not just to
in-patient services. The diverse and disparate nature of the many services
provided by the Trust, and the fact that many of them are done so in
partnership with other agencies, means that details of local arrangements
may vary, however, there should be adherence to the general principles
outlined under “Principles of Good Practice” where these are relevant and
appropriate. These local arrangements for referral, clinical handover and
discharge will be detailed in individual teams operational policies. Trust staff
working in services for which another agency has lead management
responsibility are governed by the policies of that agency, where these relate
to operational matters such as /patients entering and leaving the service.
Since 1 April 1993, it has been the responsibility of the Local Authority to
meet the social care and housing needs of patients while the Health
Service is responsible for the continuing healthcare of patients. It is the
duty of the relevant Primary Care Trust and Local Authority to provide, in cooperation with relevant voluntary agencies, aftercare services for any person
to whom section 117 of the Mental Health Act applies, until such time as the
Primary Care Trust and the Local Authority are satisfied that the person
concerned is no longer in need of such services.
All references to the Mental Health Act (1983) include those amendments
contained in the Mental Health Act (2007)
2.
Purpose and scope of the Policy
The overarching framework for the delivery of this policy is effective risk
management which will be delivered paying particular attention to the
following policy areas for consideration.
• Do Not Attempt Resuscitation
• Patient Identification
• Safeguarding adults
• Safeguarding Children
• Infection Prevention and Control
• Healthcare Associated Infections Risk Assessment
• Falls strategy
• Nutritional Screening Framework
• Guidelines for medicines reconciliation on admission
• Pressure Care guidance
• Care Programme Approach policy
• Record keeping.
• Escort Policy
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Discharge and Clinical Handover of Care 3.1.November 2012
• Policy Guidelines for the Supportive Care and Observation of
Clients within Mental Health Service
• Supervised Community Treatment order policy
Specific risks for consideration
• Physical health needs-diabetes, epilepsy allergy status for
example
• Safeguarding adults and children issues risk to individual or
others
• Risk assessments regard self care abilities, risk of self neglect
• Communication or language issues
• Advanced Directives
• Refusal of blood or plasma products
• Risk of suicide or self harm
 Safe escort and transfer between points
 Diversity Issues
The purpose of the policy is to ensure that good clinical processes are in
place to support an individuals discharge and clinical handover of care within
trust services as well as meeting good practice for those individuals whose
discharge or clinical handover of care takes them outside of trust services.
That these processes are supported through multi-agency approaches and
have the safety of individuals at the centre of decision making.
The policy is required to identify and facilitate the delivery of good practice
In identifying the good practice the policy will guide clinicians in the safe and
effective practices supporting discharge and clinical handover of care.
The following core values and principles are embedded within the policy
 Value of communication
.
The giving and receiving of information supporting discharge and clinical
handover of care
How discharge and handover of care is recorded
 Risk management
Identification and positive management of risks which are linked to the
discharge and clinical handover of care processes. Manage risk
proactively and effectively.
 Safeguarding
The protection and preservation of individuals where issues relating to
personal safety and the safety of others are identified within the
discharge and clinical handover of care processes
 Promotion of effective clinical outcomes
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Discharge and Clinical Handover of Care 3.1.November 2012
 Promote best care management of people and their carers across
service boundaries
 Provide effective and efficient systems for inter professional referral
treatment and support.
The transfer of patients between NHS premises can be emotionally and
physically demanding for patients. It is the duty of staff to facilitate a smooth
and risk free transfer which is comprehensive both at the planning stage and
point of transfer. All communication verbal and written will be comprehensive
and facilitate positive outcomes for the individual. It should in all instances
(except emergency care) be well planned for and take place within existing
care planning approaches and involve the patient and carers.
The purpose of the procedure is to provide guidance on the transfer of
individuals between services and ensure the delivery of best practice, in order
that we:
• Promote effective clinical outcomes
• Promote best care management of people and their carers across
service boundaries
• Ensure carers are supported in their role and have a choice about
their continuing role and responsibilities
• Provide effective and efficient systems for inter professional
referral treatment and support.
• Manage risk proactively and effectively.
The risks of not having this document in place are:
• Poor Patient Experience
• Limited effectiveness of Care Package Treatment
• Inappropriate Care or Treatment
• Adverse event death/suicide
• Risk of Harm to others – safeguarding Adults/Children
• Potential for complaint/litigation
• Contravention of Mental Health Act legislation
• Non compliance with Care Quality Commission or National Health
service litigation authority standards
• Non compliance with NHS Constitution.
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Discharge and Clinical Handover of Care 3.1.November 2012
3
Definitions
Care
Coordinator
Person responsible for the coordination of assessments,
care/support planning and review of a service user’s care/support
under the Care Programme Approach/Standard care.
Care/Support
A record of the arrangements which have been put in place to
Plan
meet or assist in meeting an individual’s activities or daily living,
taking into account that person’s mental, physical, and social care
needs and aspirations. This plan may also address the perceived
needs of a person in a given set of circumstances e.g. a
contingency plan in case of sudden deterioration.
Communication The act of passing or receiving information relevant to the needs
of a service user/patent in the context of his/her care. This may
be in the form of direct conversation – face to face or via
telephone, or through the written word utilising a range of media
which is most appropriate in the circumstances, e.g. RiO, letter
etc
Discharge
Discharge from services means the termination of a period of
care and treatment from a specific practitioner, group of
practitioners or care group provided wholly or in part by theTrust.
It does not imply that an individual is no longer receiving care
from other services provided by the Trust.
Clinical
Clinical handover of care means the clinical handover of a service
Handover of
user/patient to other clinical services within the Trust or to other
Care
services managed by other providers outside of the Trust
Person in
The manager of any care home or residential home into which a
charge
service user/patient is being transferred from Trust services, or
any person nominated by them to accept the responsibility for the
clinical handover of care for that service user/patient
Responsible
The approved clinician with overall responsibility for the care of a
Clinician
service user/patient detained under the Mental Health Act.
Lead Clinician
A Lead Clinician is a professionally accountable person (this may
or may not be the Care Co-ordinator) who will lead on an aspect
of an individuals care e.g. Clinical Psychologist. They would be
expected to make decisions and share information regarding the
outcomes of their work within the context of this policy, supporting
good practice around discharge and transfer.
RiO
SYSTMONE
The Care
Programme
Approach
The Trust’s chosen software application in mental health services
for the management of individual health care information.
Electronic record system for nursing services
Is a responsibility placed upon the Local Authority and the
National Health Service to meet the continuing social care,
housing needs, and healthcare of service users who have been in
receipt of secondary specialist mental services and have complex
needs.
Individuals on CPA are likely to have some of the following
characteristics:
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Discharge and Clinical Handover of Care 3.1.November 2012
 A severe mental disorder with a high degree of clinical
complexity
 Significant impairment of function due to mental illness
 They require inter-agency co-ordination
 A significant history of severe distress/instability or
disengagement
 Presence of non-physical co-morbidity e.g. substance/drug
misuse
 Currently or recently detained under the Mental Health Act
 Have current or potential risks, including:
- suicide, self-harm
- violence
- Self neglect
- vulnerability
 Significance reliance on carer(s) or has own significant caring
responsibilities
 They have unsettled accommodation/housing issues
 Experiencing disadvantages or difficulty as a result of their
mental health, particularly in relation to:
- parenting responsibilities
- Physical health problems/disability
- employment issues
- issues relating to ethnicity/race/culture
Standard Care
The te The term ‘Standard Care’ describes the approach used in
secondary mental health care for those individuals not on CPA. The
characteristics of those on ‘Standard Care’ will include some of the
following:
 They have more straightforward needs
 Receive support from one agency, or
 No problems with access to other agencies
 Present with lower risk
 They require minimal co-ordination support
 They are more able to self-manage their mental health
problems
The Mental
An Act of Parliament applicable to persons in England and
Health Act
Wales. It covers the reception, care and treatment of mentally
disordered persons, the management of their property and other
related matters. In particular, it provides the legislation by which
people suffering from a mental disorder can be detained in
hospital and have their disorders assessed or treated against
their wishes,
Service
An individual receiving services from the Trust
user/Patient
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Discharge and Clinical Handover of Care 3.1.November 2012
4.
Duties and Responsabilities
Executive Management Team
The Executive Management Team is responsible for the approval of the
policy, its dissemination and implementation.
Lead Director
The lead director is The Director of Nursing, Clinical Governance and
Safety who is responsible for ensuring that the policy is reviewed on a
regular basis and remains fit for purpose. Any review of the policy will be
instigated and led by the lead director, who take the revised policy to the
Executive Management Team for approval
Service Managers
Service Managers are crucial in the process of implementation of the
policy, ensuring that staff are trained in or have a full awareness of the
requirements of the policy. Clearly, service managers must ensure that
staff have access to the policy and any associated documentation which
might be required for its full implementation. They also ensure that local
reviews are conducted following the implementation of the policy which
might contribute to the review of the policy.
Staff
All staff employed in a clinical capacity or who manage clinical services
need to be aware of the policy, in particular those “in charge” of units or
wards or carrying individual case loads.
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Discharge and Clinical Handover of Care 3.1.November 2012
5.
Principles
The overarching principles of this document are those contained within the
NHS Constitution with particular regard to the safe and effective transfer of
patients. The transfer of patients should be carried out in such a way it
ensures a positive patient experience and maximises the effectiveness of the
care pathway.
There are key principles which underpin effective discharge and transfer of
care which are detailed by the Department of Health(2003):










The process of transfer and discharge takes place within a ‘whole
systems approach’ to assessment processes and the commissioning and
delivery of services
The engagement and active participation of individuals and their carer(s)
as equal partners is central to the delivery of care and in the planning of a
successful transfer
The transfer of patients is a process and not an isolated event. It has to be
planned for at the earliest opportunity across the primary, hospital and
social care services, ensuring that individuals and their carer(s)
understand and are able to contribute to care planning decisions as
appropriate
The process of planning a transfer should be co-ordinated by a
clinician who has responsibility for co-ordinating all stages of the
‘patient journey’ through to the transfer of responsibility following
successful completion of the handover of care process.
Staff should work within a framework of integrated
multidisciplinary and multi- agency teams, working to manage all
aspects of the transfer process.
The journey between services and method of transport will form
part of the planning process and include risk assessment and
planning to meet individual needs and risks.
Comprehensive care planning and risk management will be an
Integral part of the transfer process and will be enabled by effective
communication both written and verbal
During any transition of care,service users/patient’s who are referred to
another part of the trusts services and/or other organisations, the team
taking over responsibility should be actively involved in the planning.
In mental health consideration should be given to joint visits where feasible
and a recording made in the clinical record evidencing this decision
In mental health recording should be made in the clinical record of
acknowledgement of acceptance of the referral from the receiving
individual/ team
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Discharge and Clinical Handover of Care 3.1.November 2012
5.1
Discharge and clinical handover of Care
Discharge and clinical handover of care must be underpinned with the
sharing of information covering background details, relapse signatures,
risks, key interventions, medication and aims and objectives of care. Any
changes to the care pathway must be clearly documented in the clinical
records. This will include recording referral and discharge information. The
clinical record is an important Information sharing resource. Where
available, electronic clinical record systems are accessible by all those
involve in delivering clinical services within the trust and will have readily
available the information identified above
5.2
Discharge and Clinical handover to other health care establishments
and prisons
Discharge and clinical handover of should normally be carried out as part of a
planned care process unless it is an emergency.
Any decision to transfer the care of a service user/patient to another area
must be agreed at a review of the individuals care or support plans to meet
the individual’s needs. As an example this would be a CPA or Standard
Care review meeting in mental health services. Until transfer arrangements
are agreed, the current care co-ordinator, lead clinician or individual with
clinical responsibility should maintain clinical responsibility. Wherever
possible the service user/patient concerned should be involved in any
decision making relating to discharge and clinical transfer of care
Prior to an out-of-area transfer, the care co-ordinator/lead
clinician/individual with clinical responsibility must ensure the following has
been agreed:
 The receiving team/agency have taken responsibility for assessing the
service user and, if appropriate appointing a care co-ordinator/lead
clinician/ individual with clinical responsibility
 The service user has been advised and, where necessary, supported in
changing GP registration.
 Services are set up within the receiving team/service to meet the service
users assessed needs.
 All risk information has been shared with the receiving team/service.
 All decisions throughout the process must be agreed and communicated
in writing to the service user, their carer, where appropriate, and all
members of the care team.
 Any individual transferred to care services outside of the Trust should
have the following information transferred with them as a minimum
standard.
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Discharge and Clinical Handover of Care 3.1.November 2012
The information includes everything the other service, individual, team or
agency will need to ensure the needs of the person who uses services are
met safely, even when the transfer of information is required urgently. As a
minimum this includes:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Their name
Gender
Date of birth
Address
Unique identification number where one exists
Emergency contact details
Any person(s) acting on behalf of the person who uses services, with
contact details if available
Records of care, treatment and support provided up to the point of
transfer
Assessed needs
Known preferences and any relevant diverse needs
Previous medical history that is relevant to the person’s current
needs including general practitioner’s contact details
Any infection that needs to be managed
Any medicine they need to take
Any allergies they have
Key contact in the service the person is leaving
Reason for transferring to the new service
Any advance decision
Any assessed risk of suicide and homicide and harm to self and
others
The information is transferred in time to make sure that there is no
delay to the assessment of needs by the ser vice, team, individual or
agency
There are no interruptions to the continuity of care, treatment and
support for the person who uses services
Mental health (RiO)
A letter can be generated by the RiO supporting the above sharing of
information. For other teams not currently using RiO, a manual or agreed
template letter should be used capturing the above information
requirements. A good practice example in mental health where RIO is
used is:
Completion of the Client Transfer Information Document on RiO (Editable
Letters) with the attached Health and Social Care assessment, risk
assessment documentation and any Advance decision will meet the
transfer requirements as identified above.
5.3
Transfer Requirements for all services
All staff involved in making arrangements for the transfer of a patient
must ensure that:
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Discharge and Clinical Handover of Care 3.1.November 2012
5.4

All patient assessments (including those related to risk) and plans of care
are completed and that all documentation (including electronic, paper and
medication) are up to date and are transferred with the patient as
appropriate, ensuring adherence to data protection and confidentiality at
all times. When undertaking patient assessments and formulating plans of
care consideration should be given to the potential impact in relation to all
equality groups in order to identify any negative impact or adverse affect
that may arise and ensure appropriate action is taken to mitigate this

Referral forms for transfer to another service are completed as
appropriate, as per individual service requirement. All risks are highlighted
and communicated as necessary.

Liaison between the professionals and or service takes place as
necessary in order to confirm the plan of care, acceptance of and the date
and timeframe of transfer. This will be documented.

That any patient equipment, medical cover, transport and medication
required is in place and any services needed by the patient are ready as
agreed. This will be documented

The patients’ personal property and belongings will be transferred safely
and respectfully and will be documented

They communicate with the patient, their family, and any carers and as
appropriate, that they are involved in planning the transfer. If a patient
refuses to be transferred that support and guidance is sought from
operational managers to support the process of satisfactory and
appropriate resolution.

Confirmation of transfer once it has taken place is documented. This
should include detailed records of handover, risks to patient or others

When transferring a patient to another care setting it is vital to inform the
receiving service, unit or ward if the patient has an infection. This can be
done by completing the inter-health care transfer form. This will comply
with the Healthcare Associated Infection risk assessment policy for
admission, discharge and transfers

Comply with all other ratified polices and guidelines that are
relevant.
Transport from In-patient services
 It is the ward nurse’s responsibility to arrange appropriate transport for the
patient which could be private transport, voluntary transport organisations,
medi car or ambulance .It is the nurses responsibility to conduct a risk
assessment with regard to provision of escort. Consideration should be
given to safe transport including physical fitness to travel and any
presenting risks such as risk of absconding. Proportionate and reasonable
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Discharge and Clinical Handover of Care 3.1.November 2012
measures such as locking of doors and suitability of escort should be
considered.
5.5

Where aspects of this procedure are delegated to a member of staff who is
undertaking escort duty, the nurse delegating those duties should be
assured of the ability of the escort to undertake the role to the standards
required by this procedure

The referring unit remains responsible for the provision of care until the
patient arrives and is accepted

Under the Mental Capacity Act an Independent Mental Capacity Advocate
(IMCA) must be instructed, and then consulted, for people lacking capacity
who have no-one else to support them (other than paid staff), whenever it
is proposed to arrange accommodation in another hospital or care home
and the person will stay in hospital for longer than28 days or in the care
home for longer than eight weeks. Further responsibilities are explained in
the Mental Capacity Act Code of Practice in Chapter 10
Out of hours discharges and clinical handover of care.
The process for out of hours transfers for both inter and intra hospital transfer
is the same for that contained within this policy
On occasions where the needs of the service user necessitates the transfer to
another ward at short notice, the nurse in charge, acting on instructions of the
consultant or medical officer, will co-ordinate the transfer and ensure the
Following:

That full liaison with the receiving ward occurs prior to transfer.

That bed availability and staffing levels on the receiving ward are
appropriate and adequate to meet the needs of the service user

The service user/patient and carer/relative are fully informed prior to the
transfer taking place

All health records are complete and up to date and accompany the service
user/patient upon transfer to the receiving ward.

Consideration should be given to the preventative measure nursing in
isolation where a full and comprehensive handover is not available due to
the nature of transfer. (Control of Infection Isolation policy)

Agreement of the patient to transfer should be documented.

In emergency situations when a patient is unable to agree to transfer, the
responsibility for transfer rests with the consultant in charge of the patient’s
care however relatives should be made aware of the transfer decision as
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Discharge and Clinical Handover of Care 3.1.November 2012
soon as is practicable. All patient records and information transferred
between organisations must be treated confidentially as governed by the
Data Protection Act 1998. Disclosure of information should justify the
purpose and everyone should be aware of their responsibilities.

5.6
In the case of emergency admissions the relevant risk information must be
communicated and followed up with written communication
Planned Discharge
 The care co-ordinator/lead clinician/individual with clinical responsibility
actively in-reaches and co-ordinates discharge planning.
 The lead clinician/responsible clinician /individual with clinical
responsibility, in conjunction with others involved in the patients
care, must be satisfied that everything reasonable and practical has
been done to provide each patient with the care required in order for t
them to move on to the next stage of their care. This may take the
form of clinical handover to another part of the service, discharge from a
particular element of the service or discharge from the Trusts services.
The ultimate responsibility for discharge lies with the care coordinator/lead clinician/responsible clinician/individual with clinical
responsibility
 Those taking individual decisions about discharge from a clinical service
have a fundamental duty to consider both the safety of the patient
and the protection of other people. A patient should not be
discharged unless and until those taking the decision are satisfied that
he or she can live safely in the community, and that proper treatment,
supervision, support and care are available.
 Service users subject to sections 3, 17A, 37, 45a, 47 or 48 of the Mental
Health Act 1983 (unless subject to restriction) are considered for
supervised discharge as part of normal discharge/section 117 planning.
Any application for supervised discharge must be made whilst the service
user is detained under the Act.
 Service users subject to Hospital Orders, or who are otherwise considered
to pose a potential risk to the public may meet the criteria for Multi Agency
Public Protection Arrangements (MAPPA) registration. Where this is the
case, or is suspected, the matter should be made known to the area
MAPPA nominated officer.
 All service users discharged from hospital in mental health service will
receive 7-day follow-up.
 The GP will have a copy of the discharge plan and the contact details of
the care co-ordinator/lead clinician/individual with clinical responsibility
where clinical contact continues
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Discharge and Clinical Handover of Care 3.1.November 2012
5.7
Transfer to acute services (Mental health)
In most cases, transfers to acute services are undertaken in emergency
situations such as a sudden and severe physical illness. Where a service
user in these circumstances already has inpatient status, such a transfer is
usually undertaken in the form of leave of absence – this is discussed in more
detail below under “Leave of Absence”. If the service user concerned is
subject to detention under the Mental Health Act, then this must be facilitated
through the use of section 17 of the Act.
Only in rare and unusual situations is a service user subject to detention
transferred under section 19 of the Act, thus rendering the admitting hospital
responsible for on-going care, including mental health care. If transfer under
section19 is being actively considered, then it is imperative that advice is
sought from the Trust’s Mental Health Act advisors before any such
decision is finalised.
Service users who are not inpatients and who require acute health care will
not be discharged from Trust services. The lead clinician will make
arrangements to support the service user’s specialist mental health/learning
disability or physical health needs whilst in the acute health care service and,
when appropriate, will agree the transfer of care co-ordinator/lead clinician/
lead clinical responsibility
5.8
Disengagement from services
 Service users should not be discharged back to primary care simply
because they have disengaged without a full consideration of their
mental health and risk factors, and clear communication of this to the
GP. See the Trust DNA/NAV Policy fir further guidance.
http://nww.swyt.nhs.uk/docs/Documents/872.pdf
 If the care plan ultimately fails to engage the service user, the multi-
disciplinary team may conclude on review that the person’s needs are
best met by primary care. An action plan to manage identified risks
should be agreed with primary care, which will identify specific
indications for re-referral.
 People with a history of significant violence when mentally unwell should
not be discharged back to primary care unless there is an explicit care
plan in place that has been discussed with primary care and agreed with
the Clinical Lead. This will include a risk assessment (stating who may
be at risk), a crisis plan and specific indication for rapid re-referral.
 The discharge procedure should also be followed where the service is
unable to work directly with a person but has identified a potential for
significant risk to self or others arising from a mental health problem. In
addition, the relevant team should set up a crisis care plan enabling the
person to access services promptly through a named care co-ordinator
should they choose.
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Discharge and Clinical Handover of Care 3.1.November 2012
5.9
Outcomes of Assessments
Following the initial assessment or subsequent re-assessments of an
individual when it may be identified that other services may be required,
which may or may not be managed through the Trust, i.e. Drug or Alcohol
services, this must be fully communicated to the care team of the individual
including the GP.
In situations where a referral to the identified service cannot be made by a
member of the Trust and requires the GP or other commissioning service,
this should be communicated by telephone and followed up by letter to avoid
any delays in the referral.
5.10
Principles of Good Practice
 Discharge planning should take place at the earliest stage possible during
an episode of care. If admission as an inpatient is possible discharge
planning should begin either prior to admission or as soon as possible after
admission.
 A review of care will be facilitated by the Care Co-ordinator/lead
clinician/responsible clinician/individual with clinical responsibility to
support discharge planning. This review will include:
1. The assessment/Review of health and social care needs.
2. The assessment/Review of Risk and Risk management plans
3. Identification of outcomes to support discharge planning
4. Care planning to support timely discharge
5. To agree arrangements for 7 day follow-up (Where applicable)
6. To formulate the care plan on discharge
 Confidentiality must be preserved throughout the service; however, it is
acknowledged that in some relatively rare situations, associated risks to
others must be taken into account in decision making concerning
confidentiality issues. One example is where a child is at risk as a result of
a parent's mental health problems and a balance must be achieved
between the needs of the parent and the child.
 Each service user/patient on a mental health in-patient ward will have a
named nurse/professional who under the lead direction of the Care Coordinator/lead clinician/responsible clinician/individual with clinical
responsibility will have responsibilities for his or her in-patient care and
for assisting in co-ordinating the individual service user's discharge
arrangements. This will be done in consultation with the multi-disciplinary
team.
 Service users and their carers should be fully involved where possible and
appropriate in arranging discharge and aftercare arrangements, with
choices given wherever possible
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Discharge and Clinical Handover of Care 3.1.November 2012
 Information should be provided to service users and where appropriate
their friends, relatives and carers at all stages of organising discharge
planning.
 Prior to discharge a care plan supporting discharge and relapse
prevention will be in place and agreed. This will be communicated to all
involved agencies. This is the responsibility of the Care Coordinator/lead clinician/responsible clinician/individual with clinical
responsibility who may delegate actions to other involved persons.
 The care plan supporting discharge will clearly identify the person
responsible for 7-day (where applicable)follow-up and a time and date
will be recorded. (This is applicable to Mental health In-patient services)
 The care plan (mental health) on discharge will allow for more intensive
provision of care in the first three months after discharge and will identify
how community living is supported.
 Any discharge planning must take into consideration the requirements of
Safeguarding issues regarding the protection of children and adults.
 All service users are entitled to request an independent advocate at any
stage in their care (advocacy is the process of representing the needs and
wishes of another person).
 All those involved in the care of the individual will have access to the care
plan. In circumstances this may involve the service user giving permission
if not implied consent.
 Adequate information should be provided to the responsible individual
when service users are discharged or transferred to residential settings
including information relating to health care.
 Discrimination must not take place on grounds of age, social class, ethnic
origin, religion, language, sex, marital status, responsibility for dependants,
physical or sensory impairment, learning disabilities, mental health, sexual
orientation, body size, HIV status, diagnosis, financial circumstances or
behaviour (unless in breach of written rules or procedures).
 Wherever possible a service user should be able to choose the sex of the
professionals involved in their care.
 Service users with communication difficulties for example, people whose
first language is not English, should have access to interpreters.
 Particular care should be paid to discharge arrangements where the
service user is being discharged outside of the local authority area in which
they previously lived, to ensure adequate involvement and communication
and agreement of the care plan with the new care team.
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Discharge and Clinical Handover of Care 3.1.November 2012
 Any unplanned discharge, i.e. a person taking their own discharge, will
require a review to be facilitated by the care co-ordinator/lead
clinician/responsible clinician/individual with clinical responsibility. Within
mental health this CPA review should occur within2 working days of
discharge.
 Where a service user is discharged from all aspects of care delivered by
the Trust, a comprehensive summary of the service users care and
treatment is provided to their GP for future reference. The responsibility for
this is with the discharging clinician
5.10.1
48 hour Follow-up from hospital discharge (Mental health)
Following discharge, all inpatients assessed as at increased risk due to the
following factors, must receive follow up (face-to-face contact with a mental
health professional) within 48 hours of discharge from hospital:
1.
2.
3.
4.
5.
Attempted self harm during admission
At risk of suicide during or in the 3 months prior to admission
Living alone
At ongoing risk owing to continual disengagement from services
Living with a child under the age of 16
Service users (Mental Health) discharged from hospital must receive 7
day follow-up, including those who discharge themselves.
5.10.2
7day follow-up. The requirement that people discharged from acute mental
health in-patient care should receive a follow-up home visit within 7 days of
being discharged from inpatient care was introduced to manage the high
suicide risk at this point in the care pathway.
7 day follow up was first proposed in 1999 in the Safer services report of
the National confidential inquiry into suicide and homicide by people with
mental illness (1). The rationale for this recommendation was based on the
following findings of that inquiry:
o
o
o
o
24% of suicides occurred within three months of discharge from
inpatient care.
These post-discharge suicides were at a peak in the first week after
leaving hospital; within the first week, the highest number occurred
on the day after discharge
41% of post-discharge suicides occurred before the first follow-up
appointment.
Post-discharge suicides were associated with final admissions
lasting less than 7 days, readmissions within 3 months of previous
admission and “patient-initiated” discharge.
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Discharge and Clinical Handover of Care 3.1.November 2012
5.10.3
Implementation of 7day follow-up - the needs of individuals being
discharged from a period of in-patient care
Whilst it is good practice for all service users being discharged from
inpatient care to receive 7 day follow-up, this should be clearly incorporated
into discharge plans, recognising individual risks. Contact following
discharge should meet the individual’s needs with regards to isolation and
vulnerabilities, and should deliver an appropriate level of post discharge
support covering weekends as well as weekdays. Consideration should be
given to services such as Intensive Home Based Treatment teams and
crisis teams as examples.
The care plan supporting discharge will clearly identify the person/team
responsible for 7-day follow-up and a time and date will be recorded.
The majority of adult service users who are admitted to one of the Trust’s
acute mental health inpatient wards will already be known to and under the
care of, or ‘open’ to, one of the Trust’s main mental health teams which
support people in the community i.e. either a Community Mental Health
Team; an Early Intervention in Psychosis Team; or, an Assertive Outreach
Team. In these cases 7 day follow will be the responsibility of the care coordinator/ local BDU agreement
Some individuals who are admitted to one of the Trust’s in-patient wards
will not be known to Trust services but will be assessed and referred on to
one of the community teams for further care and treatment. In these cases
7 day follow will be the responsibility of the care co-ordinator/ local BDU
agreement
Some individuals who are admitted to one of the Trust’s in-patient wards for
the first time will during admission be assessed as not requiring further
input or treatment from any of the community teams once they leave
hospital. Individuals deemed not to require future treatment from or referral
on to mental health teams will be discharged back to primary care. In these
cases, a one-off 7 day follow-up visit will be carried out by teams agreed to
undertake this role within each of the BDU’s after which the person will be
discharged back to primary care. Any exceptions to this must be clearly
documented within the clinical record
Where individuals do not attend their 7 day follow-up appointment/s or do
not allow access for follow-up within their home environments. The Trust’s
DNA/NAV policy must be followed
http://nww.swyt.nhs.uk/docs/Documents/872.pdf
5.11
Continuing Care
After a stay in hospital most service users are able to return to their own
homes, others may need some continuing care.
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Discharge and Clinical Handover of Care 3.1.November 2012
Often continuing care is provided outside the NHS either in a nursing or
residential home or a complex package of social care in the community.
When a service user does not agree with arrangements that have been
made for discharge into continuing care they do not have the right to occupy
an NHS bed indefinitely. They do have the right to refuse to be discharged
from NHS care to a nursing or residential home. In such cases it is the
responsibility of the Local Authority to explore alternative options including
the possibility of discharging the service user to his home or alternative
accommodation.
It is the responsibility of Primary Care Trusts and Local Authorities to agree
eligibility criteria for access to continuing health care from the NHS. The
continuing care eligibility criteria agreed locally are identified in a separate
joint Primary Care Trust policy. This is an important issue as individuals who
are not eligible to receive ongoing care from the NHS but are eligible to
receive care from Social Services will undergo a financial assessment and
may therefore be required to contribute financially to their aftercare
arrangements. Where the service user or their relatives are accepting
responsibility for funding a nursing or residential home placement on
discharge, the appropriate consent form should be signed to prevent any
confusion regarding responsibility for payment at a later date.
5.12
Medication Management
Health care professionals transferring a patient should ensure that all
necessary information about the patient’s medicines is accurately recorded
and transferred with the patient, and that responsibility for ongoing
prescribing is clear.
2. When taking over the care of a patient, the healthcare professional
responsible should check that information about the patient’s medicines
has been accurately received, recorded and acted upon.
3. Patients (or their parents, carers or advocates) should be encouraged to
be active partners in managing their medicines when they move, and know
in plain terms why, when and what medicines they are taking.
4. Information about patients’ medicines should be communicated in a way
which is timely, clear, unambiguous and legible; ideally generated and/or
transferred electronically.
Recommended core content of records for medicines when patients
transfer care providers
Patient details Last name, first name, date of birth, NHS number, patient
address
GP detailsGP/Practice name
Other relevant contacts defined by the patien
Allergies Allergies or adverse reactions to medicines, including causative
medicine, details of reaction, probability of occurrence
Medications Current medicines, including name, indication, form, dose
strength, frequency, time and route
Medication changes Medication started, stopped or dosage changed, and
reason for change
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Discharge and Clinical Handover of Care 3.1.November 2012
Medication recommendations e.g. duration of treatment and/or review,
ongoing monitoring requirements, advice on starting, discontinuing, or
changing medicines. Consideration should be given to the risk of self harm
and limited supplies issued if required.
Requirements for adherence support, for example, compliance aids,
prompts and packaging requirements.
Person completing record
http://www.rpharms.com/current-campaigns-pdfs/1303---rps---transfer-ofcare-10pp-professional-guidance---final-final.pdf
http://nww.swyt.nhs.uk/medicines-code/Documents/Section-3.pdf
http://nww.swyt.nhs.uk/docs/Documents/949.doc (NPSA alert, omitted and
delayed medicines)
http://nww.swyt.nhs.uk/docs/Documents/849.doc (Medicines
Reconciliation on admission to hospital)
5.13
Mental Health Act (1983) Section 117 - Mental Health
The requirements of Section 117 apply to people who have been detained
under Sections 3, 17A, 37, 45a, 47 or 48 of the Mental Health Act 1983.
When the decision to discharge or grant leave to a service user who has
been detained under one of these sections is made, it is the responsibility of
the responsible clinician to ensure that;
 in consultation with other professionals concerned, a comprehensive
assessment is made of risks to the service user or other people, and
communicated to the Care Programme Approach Co-ordinator,
 the service user’s needs for health and social care are fully assessed and
a care plan is developed to meet the service users’ continuing needs,
The requirements of Section 117 apply even if the service user has remained
in hospital informally or has been discharged as the result of a Mental Health
Review Tribunal or Hospital Managers’ Review of Detention.
Section 117 responsibilities continue until both health and social services
agree that aftercare services are no longer required. This decision must only
be taken following a formal review of the care package.
For further guidance refer to the Mental Health Act, 1983 and its Code of
Practice.
5.14
Supervised Community Treatment (Mental health)
Supervised Community Treatment provides a framework for the
management of care in the community to those patients to whom the
procedure applies. It aims to allow suitable patients to be treated safely in
the community, rather than under detention in hospital, and to provide a
way to help prevent relapse. It gives the responsible clinician the power to
recall the patient to hospital for treatment if this is felt necessary.
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Discharge and Clinical Handover of Care 3.1.November 2012
5.15
Discharge against Medical Advice (mental health)
If a service user who is not subject to detention under the Mental Health Act
decides he wishes to leave hospital and take his own discharge, the nurse in
charge discusses with the service user the reasons for wanting to leave and
attempts to dissuade the service user from doing so. The service user is
encouraged to wait to see a doctor before he leaves.
If the service user cannot be persuaded to stay they should be asked to sign
a declaration (see Appendix 3) that they are leaving hospital against medical
advice and should be given a clear explanation of what this means. A copy of
the declaration should be fixed in the medical notes. The nurse in charge
must give due consideration to detaining the service user under section 5(4)
of the 1983 Mental Health Act (Nurse’s holding power) (see Mental Health
policy –“Nurse’s Holding power” Similarly, if the duty medical officer has been
summoned and cannot persuade the service user to remain, he should
consider the use of the Doctor’s Holding Power
Reassurance should be given that the service user’s decisions will not effect
any future treatment or care he may require but if the service user is still
determined to leave; his consultant (or Duty Medical Officer if out of hours)
should be informed without delay. If a service user refuses to sign the
declaration then the nurse in charge must state this on the declaration and in
the service user's notes, sign the form and have it witnessed. If the service
user refuses to wait for necessary transport or other arrangements to be
made before he leaves, the nurse in charge must be satisfied that every effort
to persuade the service user against this course of action was made. The
service user's relatives/carers and the General Practitioner must be notified
as soon as possible of his departure. Other professionals involved in the
service user’s care particularly where booked sessions may need cancelling,
should be notified by the nurse in charge of the ward/unit as soon as
practicable.
Should it be found that the service user has left the hospital without notifying
anyone, the missing service user procedure - must be implemented.
Where a service user already has a Care Co-ordinator the co-ordinator
should be notified and the Named Nurse/Professional (or other person
nominated by the nurse in charge) and the Care Co-ordinator will then be
responsible for developing an interim care plan detailing the immediate
action to be taken. Where a Care Co-ordinator has not been established, the
Named Nurse/Professional will be responsible for ensuring an interim care
plan is developed (including immediate action to be taken), in consultation
with others involved which will include referral to appropriate aftercare
services.
5.15.1
Discharge against Medical Advice (non mental health)
Documentation will be completed as per agreed protocols
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Discharge and Clinical Handover of Care 3.1.November 2012
5.16
Leave of Absence (if the service user is detained under the Mental
Health Act please refer to the s17 policy )
Leave of absence from a ward or unit is often used as an adjunct to the
discharge process. Service users may be granted short (overnight or
weekend) periods away from the ward, usually in the service user’s own
home, but occasionally with formal or informal carers in other locations.
Sometimes such leave is for longer periods of time, where the service user
is away from the hospital for a week or more, but his or her in-patient status
remains. In some circumstances leave of absence might be used to
facilitate treatment in an acute hospital setting e.g. because of a sudden
and acute physical illness. Irrespective of the reasons, it is clear that the
service user is not yet ready for discharge it must be assumed that he still
has needs which cannot be met fully in the community. Therefore all
periods of leave involving overnight stays must be planned carefully using
the Care Programme Approach as outlined in this policy. Clearly, not all
aspects of CPA will be applicable, but certain key matters must be
addressed before the service user proceeds on even the shortest period of
overnight leave, these are.
 The leave must form part of a programme of care, and as such have an
associated written plan of care
 The appropriateness of weekend leave, when support services are not
generally available
 It must be authorised by the consultant or another doctor appointed by him
 Any medication required by the service user during the period of leave
must be ordered and obtained before the leave commences
 Details of the service user’s leave must be communicated to other
professionals concerned with the service user’s care. In particular, the
service user’s care co-ordinator must be aware of, and involved in the
development of the leave care plan if the period of leave involves more
than five consecutive overnight absences from hospital care
 The care plan must contain a clear crisis plan which addresses the actions
to be taken in the event of the leave process breaking down. This will
involve the service user being provided with written information complete
with contact numbers etc.
 A contingency plan outlining actions which must be taken if the crisis plan
cannot be instigated or otherwise fails. The service user is seen by a
suitably experienced, qualified nurse immediately before the service user
proceeds on leave, who makes a final assessment of the service user to
determine that there is no evidence of gross deterioration. The nurse
records his findings in the clinical notes. NB it is not sufficient for the entry
in the clinical notes simply to state that the service user has proceeded on
leave.
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Discharge and Clinical Handover of Care 3.1.November 2012
 The service user is given unambiguous instructions about when to return
to hospital and the action he or she must take if this is not possible.
Additionally, instructions are left with ward staff as to the action they must
take if the patient fails to return to the ward.
 Where the service user has been subject to general anaesthesia on the
day of leave (e.g. because he has undergone electro-convulsive therapy)
special restrictions apply and in these circumstances the service user
should be considered as an out patient as outlined in the ECT Protocols
(p18)
5.17.
Communication with the General Practitioner
Communication with the service user's general practitioner after discharge
from a period of care is essential to enable the GP to provide for the service
user's immediate and ongoing primary health care needs. Two forms of
formal communication take place with the general practitioner on discharge
from in-patient care:
1. A Discharge Medication Summary ( example as appendix 4) is completed
on the day of discharge and signed by a member of the service user's care
team. This is posted or faxed on the day of discharge, or as soon as
possible after. It must reach to general practitioner no later than 7 days
following discharge.
2. A full medical report to be sent by the individual's Consultant/responsible
clinician to the general practitioner within 2 weeks of discharge.
This medical report relating to discharge has been developed on the
electronic record and is currently being piloted before roll-out to in-patient
services. Some service areas will continue to use paper recording formats
until this is fully established.
Where the general practitioner requires information more urgently than 7
days, this should be provided by telephone, by a member of the care team.
Where fax machines are available these may be used in accordance with the
Information Governance Policy (found here). Adequate medication for a
service user's mental and where reasonable, physical health problems needs
to be provided to cover the period until an appointment has been made to see
his or her general practitioner. Thus, where ongoing medication is not being
provided by out-patient arrangements, the general practitioner must have
available the information required, in order to prescribe the necessary
medication.
When a service user is discharged or transferred from a community service a
summary report must be sent to the service user’s GP stating the health care
activities that have been undertaken, their outcome and the reason the
service user was discharged. If the service user was transferred to another
service, either within or external to the Trust, the details of the receiving
service should be included in the report.
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Discharge and Clinical Handover of Care 3.1.November 2012
A copy of the care plan and outcomes of reviews are sent to the general
practitioner. A review often coincides with the discharge of an individual. In
mental health General Practitioners are invited to Care Programme Approach
review meetings for all service users under the Care Programme Approach.
5.18
Specific Responsibilities in Discharge Arrangements from Inpatient
Services
5.18.1
Role of Consultant/Responsible Clinician
The ultimate responsibility for the discharge of a service user lies with the
consultant/responsible clinician in liaison with the multi-disciplinary team.
1. Discuss with the service user, and multi-disciplinary team prior to
admission, if possible, the likely outcome of the episode of care, length of
stay and support likely to be needed on discharge.
2. Ensure appropriate medical assessment of all service users before
discharge; prescribe 'take home' medication, as per the Trusts Medicines
Code. ‘a supply of 14 days will be supplied unless a shorter course is
required’.
3. Ensure all service users have a care co-ordinator (mental health) prior to
discharge and an associated aftercare plan.
4. Discuss concerns raised by service users, relatives and other
professionals with regard to discharge arrangements.
5. Make it clear on a service user's discharge care plan what clinical
interventions will be required on discharge, such as follow-up medical care
or referral to other clinical services.
6. Provide the service user with certificates needed to enable him to draw
benefits.
7. Check discharge summary on day of discharge, prepared by named
nurse, particularly the diagnosis and medication and authorise with a
signature.
8. Ensure that, in the event a service user discharging himself against
medical advice, the general practitioner and care co-ordinator 9mental
health) are informed within 24 hours (by telephone) and ensure that a review
meeting is organised.
9. Dispatch formal letter to general practitioner within 2 weeks service user's
discharge.
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Discharge and Clinical Handover of Care 3.1.November 2012
5.18.2
Role of Clinical Team Manager/Ward Manager/Unit Manager
It is the responsibility of the manager to ensure adherence to this policy.
5.18.3
Role of Nurse in Charge of the in-patient facility at the time of discharge
In addition to those duties identified under “discharge against medical
advice”, the nurse in charge of the relevant ward/unit is usually the last
professional who will have contact with the service user prior to discharge
and as such has specific responsibilities.
1. Ensure that the service user has necessary medication (enough to last
until his next appointment with either GP or consultant as appropriate) and
understands the verbal and written instructions given to him.
2. Where the service user's ongoing medication is to be provided by the
general practitioner, the nurse in charge should advise the service user to
make an appointment, giving necessary assistance and advice as
required.
3. Ensure that any property, including valuables, are returned to the service
user and a receipt obtained.
5.18.4
Role of Named Nurse/Professional
Named nurses/professionals are responsible for being involved in coordinating service users’ discharge arrangements as well as their in-patient
care.
1. If at any stage during discharge planning it is likely the service user will
require social care on discharge, ensure that a social worker is involved,
and where possible any other involved agency representative e.g.
Department of Work and Pensions.
2. Ensure that discharge and aftercare arrangements are discussed with the
service user's carer, care co-ordinator and other relevant professionals or
voluntary agencies. In consultation with the care co-ordinator, ensure there
is a written aftercare plan, agreed with all the agencies involved, which
includes specific attention to the first weeks post discharge and allows for
more intensive support in the first 3 months after discharge.
3. Ensure that the date and time of discharge is discussed with the service
user, carer (where applicable) and care co-ordinator, and that
arrangements for escort and reception at destination are available.
4. Arrange any out-patient appointment, and/or day service appointment, with
transport where appropriate.
5. Re-establish clinical services (as appropriate) to which the service user
may have had access prior to admission, e.g. podiatry, clinical psychology.
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Discharge and Clinical Handover of Care 3.1.November 2012
6. Ensure that the service user has a copy of his Care Plan and
understands its content, including how to contact the care co-ordinator
and who to contact in an emergency (including out of hours).
7. Complete the discharge checklist and place in service user's records.
8. Arrange for a practitioner to make contact with the service user within
seven days of discharge from hospital.
5.18.5 Role of Care Co-ordinator (mental health)
Many service users have care co-ordinators involved before their admission.
The care coordinator will maintain their involvement during a service user’s
episode of care and will be involved in the service user's discharge.
1. Ensure that a written CPA Care Plan or clinical care plan has been agreed
prior to discharge and all services understand their role and are committed
to their input into this plan and that the service user understands the plan.
The plan will include specific attention to the first week post discharge and
allow for more intensive provision of care in the first 3 months after
discharge.
2. Ensure that the general practitioner is aware of and has a copy of the
proposed care plan and the name and contact details of the care coordinator.
3. Ensure appropriate review arrangements for the care plan have been
made.
4. Attend all the Care Programme Approach meetings prior to the service
user's discharge.
5. Ensure consideration is given to delaying the discharge where it is unclear
whether the proposed care plan can be implemented by the nominated
agencies.
6. Act as a consistent point of contact for the service user, his or her carers
and other professionals.
5.18.6
Role of Allied Health Professionals
All appropriate clinical services should have been involved in the discharge
care plan via discharge planning
1. All discharge arrangements will be discussed and agreed with the service
user and other relevant agencies before the end of that episode of care
and in conjunction with the consultant/responsible clinician and multidisciplinary team.
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Discharge and Clinical Handover of Care 3.1.November 2012
2. All service users, where applicable, using allied health professionals
services while an in-patient will be given a review appointment including a
contact name and telephone number.
3. Where relevant, all service users will be discharged from allied health
professionals’ care with the prescribed aids and individualised home
programme/intervention.
4. Allied health professionals services should liaise with the local authority
Services for provision of disability equipment and adaptations if
appropriate.
5. Clinical services available prior to admission should be reorganized as
appropriate.
5.18.7 Role of Social Services
Depending on the requirements of the service users, social workers work as
part of the community mental health teams, as part of hospital social work
teams or as part of generic community social work teams. The role and
function of the social worker in connection with the discharge of service users
from hospital includes counselling service users and relatives in readiness for
discharge and assessing the appropriateness of social support services being
provided, including housing. The range of services for which the social
services department is responsible includes domiciliary help and care,
residential care services including nursing home provision and the provision
of disability equipment and home adaptations.
5.18.8
Role of Community Teams
Community Teams refers to all teams which provide management and
support to individuals receiving services under the Trust in a community
setting. This will include Community Mental Health Teams, Community
Teams Learning Disability Teams and other teams providing services for the
Trust
Multi-disciplinary/agency community teams deal with the needs of people
suffering from severe and/or enduring mental illness/Learning Disabilities
within a community setting. A large proportion of service user users being
discharged from hospital will have had contact with a community team prior to
their admission. In all probability the service user's care co-ordinator/ Care
Manager is a member of a community team and will involve other members
of the team as appropriate.
Where a service user has not had prior contact with a community team, a
referral will have been made while the service user is in hospital. Ideally a
member of the community team will have visited the service user prior to his
or her discharge and will have been involved in developing the service user’s
care plan.
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Discharge and Clinical Handover of Care 3.1.November 2012
Where this is not possible (due to the admission being of short duration),
arrangements should have been made to carry out a post-discharge
assessment of the service user in his or her home environment as soon as
possible after discharge. The service user should be fully notified of
these arrangements.
5.18.9
Specific Responsibilities for Discharge or clinical handover of Care in
Non-inpatient Areas
Service Manager
The Service manager is responsible for ensuring that this policy is followed
and will work with other agencies to ensure that transfer of care between
services is a smooth process.
Lead Clinician
The lead clinician will be responsible for assessing the appropriate time to
discharge a service user or to transfer a service user to another care
provider. They will do this in consultation with other clinicians involved in the
service user’s care, the service user and other agencies that will be affected
by the decision.
The lead clinician will liaise with the care coordinator to ensure that a
CPA/Standard Care review is arranged. They will ensure that all
assessments and reports from the service are completed and will provide a
discharge/transfer summary for the GP, and for any other person or service
who is appropriate to receive it. The lead clinician will ensure that the
discharge or transfer is recorded in the clinical notes and Trust clinical
information systems. Any local paperwork will also be completed.
5.19
Documentation upon discharge
5.19.1
Information to the service user
When discharged from an inpatient area information is provided covering
details of what can be expected in terms of follow up in the community. This
will include a copy of a Discharge Medication Summary (given at the point of
discharge) which includes contact information and follow-up services
arranged. A copy of his/her care plan including crisis and contingency plans.
A range of other information may be made available dependent upon what
other services are being provided. These will be tailored to the individual’s
needs.
All service users discharge from service will have an agreed crisis and
contingency plan in place which will be communicated to relevant primary
care services.
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Discharge and Clinical Handover of Care 3.1.November 2012
5.19.2
Letter to GP
Discharge from in-patient care/teams/services:
This is a formal letter normally composed by the service user’s lead clinician.
It includes the recent history of the service user, the reason why the service
user was admitted to the service, treatment and progress, and follow up
arrangements.
Discharge from all Trust services:
Where a service user is discharged from all aspects of care delivered by the
Trust, a comprehensive summary of the service users care and treatment is
provided to their GP for future reference. The responsibility for this is with the
discharging clinician
5.20
Electronic Records (RiO) and SYSTMONE
Electronic records are now being used through most areas of the Trust with
plans top roll out to all service areas. Rio and Systm One supports that
documentation in the electronic system is available to support the information
requirements relating to effective and safe delivery of services. This includes
assessment and care planning, review and discharge information. .RiO and
Systm One are particularly useful tools in terms of service user discharge as
it allows information to be stored and immediately available to suitably
designated professionals. Much of the information which was (and to some
extent still is during the transition to full electronic system use) written in case
notes, is now held on RiO and Sytm One.
28
Discharge and Clinical Handover of Care 3.1.November 2012
6
Equality Impact Assessment
Equality Impact Assessment Template for policies, procedures and
strategies
Equality Impact
Assessment Questions:
Evidence based Answers & Actions:
1
Name of the policy that you
are Equality Impact
Assessing
Discharge and Transfer of service users
2
Describe the overall aim of
your policy and context?
Who will benefit from this
policy?
To deliver best practice in the discharge
and transfer of service users from Trust
services.
Service users, Trust Staff and
partnership agencies
3
Who is the overall lead for
this assessment?
Director of Nursing, Clinical Governance
and Safety
4
Who else was involved in
conducting this
assessment?
Phil Tordoff – Care Programme
Approach Lead
Julie Fleetwood – Assistant director
5
Have you involved and
consulted service users,
carers, and staff in
developing this policy?
The Policy has been reviewed to
incorporate best practice in Discharge
and transitions to other services in
conjunction with The Trusts Care
Programme Approach and Care Coordination policy. The identified Policy
was produced following a lengthy
consultation with Partner agencies,
service users, carers and staff.
This is not a new function.
The core values and principles of the
Policy promote involvement, engagement
and choice. Therefore good practice will
promote equality of opportunity across all
equality groups, taking into account and
address people’s ethnicity, disability,
gender, sexual orientation, religion and
belief needs.
CPA audit will look at capturing equality
data
What did you find out and
how have you used this
information?
6
What equality data have
you used to inform this
equality impact
assessment?
29
Discharge and Clinical Handover of Care 3.1.November 2012
NO
Evidence based
Answers &
Actions
Policy
underpinned by
the key values of
Personalised and
Client Centred
approaches to
care and support
therefore it will
have a positive
impact on all
equality groups
“
10b Disability
NO
“
10c Gender
NO
“
10d Age
NO
“
10e Sexual Orientation
NO
“
10f
NO
“
NO
“
9
Taking into account the
information gathered.
Does this policy affect one
group less or more
favourably than another on
the basis of:
Where Negative
impact has been
identified please
explain what action
you will take to
mitigate this.
If no action is to be
taken please
explain your
reasoning.
10a Race
Religion or Belief
10g Transgender
11 What measures are you
implementing or already
have in place to ensure that
this policy:
 promotes equality of
opportunity,
 promotes good
relations between
different equality
groups,
 eliminates
harassment and
discrimination
13 Have you developed an
Action Plan arising from
this assessment?
YES
Monitoring:
CPA audit
service user and carer feedback
Community and In-Patient Service User
Survey 2009/2010
Dialogue groups
To review the CPA audit to capture
monitoring requirements.
If yes, then please attach
any plans at the back of
this template
14
Tim Breedon, District Service Director
Who will approve this
30
Discharge and Clinical Handover of Care 3.1.November 2012
assessment and when will
you publish this
assessment.
7
Dissemination and implementation arrangements (including training)
7.1
Dissemination
This policy will be disseminated according to the Trust’s policy for the
development, approval and dissemination of policy and procedural
documents. It will be made available to staff through the Trust intranet
system. Staff will be alerted to the policy through the Trust’s Management
Briefing process and through the Business Delivery Units management and
communication systems. Amendments to the policy will be disseminated
through the same process.
7.2
Implementation of the policy
Implementation of this policy is supported by:
a) The most up-to-date version of this policy will be available on the Trust
intranet.
b) Cross references to this process are included in the incident
management and investigations policy and procedures
c) Being open will be included in incident management and investigations
training
7.3
Training
Training in the Discharge from Services process is supported through
the Care Programme Approach Training (mental health). Training in the
Discharge from Services process in non- mental health areas will form part
of the local induction process in the team, covering any local or unusual
arrangements that are identified as part of their local protocols.
Staff supervision processes will assess competency, provide support and
identify training needs with regard to Discharge from Services.
8.
Monitoring compliance
 7 day follow up (mental health) is part of a monthly Integrated Trust
performance report
Business Delivery Units
BDU’s will undertake local audit to provide evidence of
 written aftercare arrangements for all service users on discharge
 Discharge summary to general practitioner within 7 days of discharge
31
Discharge and Clinical Handover of Care 3.1.November 2012
 Discharge medical report to general practitioner to be sent within 2 weeks
of discharge
 Audit of information shared/provided during transfers of care
9.
References
• NHS Constitution Handbook 2009 Department of Health
• Active Timely “Simple” Discharge from Hospital – A Toolkit for the
Multidisciplinary Team. London: Department of Health (2004).
• Health and Social Care Act (2008) Department of Health
• Health and Social Care Joint Unit & Change Agents Team. (2003)
Discharge from Hospital: Pathway, Process and Practice. London:
Department of Health.
• Mental Health Act code of practice (1983)
• Healthcare Acquired Infections Risk Assessment Policy for admission
Discharge and transfer.
32
Discharge and Clinical Handover of Care 3.1.November 2012
Appendix 1
3. The Care Programme Approach
The Trusts Care Programme Approach and Care Co-ordination Policy and Procedural
guidance which is founded upon Refocusing the Care Programme Approach – Policy
and Positive Practice Guidance Dept of Health 2008; will embed its values and
principles in the delivery of good practice in the discharge and transfer of service users
by:

Appointing a Care Co-ordinator to keep in close touch with the service user and
to monitor and co-ordinate care.

Setting out an underpinning statement of values and principles that all in
secondary mental health services should aim for.

Highlighting positive practice around service user and carer involvement and
engagement.

Ensuring that people using the service experience safe and appropriate care,
treatment and support that meets their needs.

Providing a clearer definition of individuals and groups who may need a higher
level of engagement and co-ordination support.

Supporting the formulation and delivery of a care/support plan, which identifies
the health and social care requirements from a variety of providers

Supporting individuals to make informed decisions about the services on offer
and have sufficient information to enable them to exercise this choice

Delivering a whole systems approach
Key groups supported through CPA are those:

who have parenting responsibilities

who have significant caring responsibilities

with a dual diagnosis (substance misuse)

with a history of violence or self harm

who are in unsettled accommodation

are unable to maintain lasting and consenting contact with services
33
Discharge and Clinical Handover of Care 3.1.November 2012
Appendix 2
Checklist for the Review and Approval of Procedural Document
Being open policy and guidance
To be completed and attached to any policy document when submitted to EMT for consideration and
approval.
Title of document being reviewed:
1.
2.
4.
5.
Comments
Title
Is the title clear and unambiguous?
YES
Is it clear whether the document is a guideline,
policy, protocol or standard?
YES
Rationale
Are reasons for development of the document
stated?
3.
Yes/No/
Unsure
YES
Development Process
Is the method described in brief?
YES
Are people involved in the development
identified?
YES
Do you feel a reasonable attempt has been
made to ensure relevant expertise has been
used?
YES
Is there evidence of consultation with
stakeholders and users?
YES
Content
Is the objective of the document clear?
YES
Is the target population clear and
unambiguous?
YES
Are the intended outcomes described?
YES
Are the statements clear and unambiguous?
YES
Evidence Base
Is the type of evidence to support the
document identified explicitly?
YES
Are key references cited?
YES
Are the references cited in full?
YES
Are supporting documents referenced?
YES
Via hypertext links
34
Discharge and Clinical Handover of Care 3.1.November 2012
Title of document being reviewed:
6.
If appropriate have the joint Human
Resources/staff side committee (or equivalent)
approved the document?
8.
9.
10.
11.
Comments
Approval
Does the document identify which
committee/group will approve it?
7.
Yes/No/
Unsure
YES
unsure
Dissemination and Implementation
Is there an outline/plan to identify how this will
be done?
YES
Does the plan include the necessary
training/support to ensure compliance?
YES
Document Control
Does the document identify where it will be
held?
YES
Have archiving arrangements for superseded
documents been addressed?
YES
Intra/internet document store
Process to Monitor Compliance and
Effectiveness
Are there measurable standards or KPIs to
support the monitoring of compliance with and
effectiveness of the document?
YES
Is there a plan to review or audit compliance
with the document?
YES
Review Date
Is the review date identified?
YES
Is the frequency of review identified? If so is it
acceptable?
YES
Overall Responsibility for the Document
Is it clear who will be responsible
implementation and review of the document?
YES
35
Discharge and Clinical Handover of Care 3.1.November 2012
Appendix 3
DISCHARGE FROM IN-PATIENT CARE AGAINST MEDICAL ADVICE
I……………………………………………………………….. am discharging myself
from hospital in-patient care against medical advice. I have had an opportunity to see
a doctor to discuss my situation.
Signed ...............................................................
Date ........................................
Name of nurse in charge ..............................................................................................
Signature of nurse in charge .............................
Date ........................................
IF THE PATIENT REFUSES TO SIGN
The patient ………………………………………….. has refused to sign the Discharge
Against Medical Advice form.
Name of nurse in charge ..............................................................................................
Signature of nurse in charge ............................
Date .......................................
Witness Name .............................................................................................................
Signature of witness .........................................
Date .......................................
This form must be filed in the patient’s medical records, an entry must also be
made in the appropriate section of RiO (where applicable)
36
Discharge and Clinical Handover of Care 3.1.November 2012
Appendix 4
37
Discharge and Clinical Handover of Care 3.1.November 2012
38
Discharge and Clinical Handover of Care 3.1.November 2012
39
Discharge and Clinical Handover of Care 3.1.November 2012
40
Discharge and Clinical Handover of Care 3.1.November 2012
Appendix 5
41
Discharge and Clinical Handover of Care 3.1.November 2012
Appendix 6
Client Transfer Information
Name:
Date of Birth:
Gender:
NHS Number:
RiO Number:
Telephone Number:
Current Address:
An OTHER
6 May 1968
Male
1130015
Room101
94 This Street
Halifax
HB1 7YT
Future Address:
GP:
Practice:
Telephone Number:
Carer:
Contact Details :
Telephone Number:
Significant other:
Care Co-ordinator:
Contact Details:
Dr xxxxxxx
THE xxxxx PRACTICE
xxxxxxx HEALTH CENTRE
659 xxxxxx ROAD
xxxxxxx, MANCHESTER
Mxx 8xx
xxx
Xxxxx xxxxxxx
Telephone Number:
Emergency Number (if different from above contacts):
Any infection that needs to be managed
Medication needs
Allergies
Reason for transferring to the new service and summary of recent care
Once printed please attach a recent Care Plan, Comprehensive Assessment and Risk
Assessment - Level 1/Level 2. Update assessment as necessary before attaching and also
send copies of any advanced decision.
42
Discharge and Clinical Handover of Care 3.1.November 2012
Appendix 7
PRIVATE AND CONFIDENTIAL
Dr xxxxxx
THE xxxxxxxxx PRACTICE
xxxxxxx HEALTH CENTRE
xxxxxxxx ROADxxxxxxxxxxx, MANCHESTER
xx7 8xx
Insert Name of office/team
Insert Location address
Insert Address
Insert Address
Insert Address
Insert Postcode
Insert Tel
Insert Fax
Insert Ref
28 Sep 2010
RiO: 1130015
NHS:
Dear Dr xxxxx
Re: An OTHER DOB: 6 May 1968
Room101 94 This Street Halifax HB1 7YT
Inpatient Discharge Summary
Date of admission:
Date of discharge:
Mental Health Act Status
Insert MHA Status
CPA Episode Start Date:
CPA Level:
Current Care Coordinator:
To be followed up by (tick where applicable)
Outpatients
CMHT
Social Services
Crisis Team
None
Other
43
Discharge and Clinical Handover of Care 3.1.November 2012
Medication on discharge
Free text
Circumstances on admission Free text
History of presenting complaint Free text
Collateral history Free text
Personal history Free text
Family history Free text
Forensic history Free text
Social history Free text
Past medical history Free text
Past psychiatric history Free text
Medication Free text
Mental state on admission Free text
Current Physical Illness Free text
Progress on the ward Free text
Please contact me if you require further information
Yours sincerely
44
Discharge and Clinical Handover of Care 3.1.November 2012
Appendix 8
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
BARNSLEY BUSINESS DELIVERY UNIT
MOUNT VERNON NURSES
DISCHARGE OF A PATIENT
LOCAL WORK INSTRUCTIONS
REF LWI 13.1(2)
1.0
APPLICABLE TO:
Mount Vernon Nurses and MDT.
2.0
PERSONNEL:
Registered Nurse.
Student Nurse under supervision.
Doctor.
3.0
RISK FACTORS:
Incorrect referral for continuity of care legislation.
Litigation.
4.0
PURPOSE:
To ensure effective discharge of a patient.
5.0
PROCEDURE:
(a)
The named nurse commences discharge plans.
(b)
The patient’s anticipated discharge date will be obtained from the Consultant at
the first ward round after admission.
(c)
Once a discharge date has been agreed, the named nurse will liaise with the
patient and relative/carer, and with the Patient’s consent give them any
relevant information relating to the Patient’s discharge such as arrangements
for any OT equipment to be delivered, if District Nursing Team needs to attend
and any transport details.
(d)
It is the named nurse’s responsibility to inform the ward clerk via the ward clerk
diary of the discharge date and of any outpatient appointments which may be
required. Details to include full discharge address and to specify if nursing or
residential home and the GP’s name and telephone number. The ward clerk
will inform the patient‘s GP of the discharge and arrange any follow up
appointments with the Consultants.
(e)
The named nurse will liaise with the appropriate health professional in
community or hospital setting and the social worker regarding provision of
services for all discharges. A copy of the contact assessment is sent to Ward
1, Mount Vernon Hospital to the Hospital Social Worker Team once discharge
date is imminent, to trigger the Social Work Assessment. The Social Worker
attends the ward to confirm receipt of referral (within 48 hours). It is the named
nurse’s responsibility to ensure appropriate specialist services are contacted
on discharge e.g. diabetic, Parkinson referral and that the patient/carers are
made aware of any external outpatients appointments eg fracture clinic.
(f)
The named nurse obtains “take home” medication by:
(i)
doctor completes D1 Form (This must state if a patient has any
infection eg MRSA and if a DNACPR decision is in place);
(ii)
give D1 Form to pharmacist who signs and takes all copies;
45
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
BARNSLEY BUSINESS DELIVERY UNIT
MOUNT VERNON NURSES
DISCHARGE OF A PATIENT
(g)
LOCAL WORK INSTRUCTIONS
REF LWI 13.1(2)
(iii)
patients who will require assistance with their medication when
discharged home will have a discharge medication referral form
completed by a Registered Nurse and the form will then be sent to the
Pharmacy for the Pharmacist to review and give advice to patient or
recommend that the patient has a Nomad system for medication if
appropriate
(iv)
take home medication is returned to ward with pink, white and blue
copy of D1 Form. The bottom yellow copy is retained by the Pharmacy
Department. Nurse in charge checks medication complies with D1
Form and treatment sheet and signs discharge plan and D1 to show it
has been checked;
(v)
receipt of medication is entered into discharge plan by the nurse in
charge;
(vi)
white copy of D1 Form is sent to patient’s own GP on discharge by
named nurse, pink copy filed in patient’s notes and blue copy is sent
with the patient;
(vii)
nurse in charge on day of patient’s discharge will explain to patient/
relative how medication is to be taken and to ask patient, with help
from relatives if needed, to complete privacy and dignity forms;
(viii)
if patient on anti-coagulants (yellow) book, (completed by doctor).
Information and anti-coagulation outpatient appointment supplied with
full explanations regarding importance of regular monitoring of INR’s.
(ix)
Ensure all patients who are discharged on Warfarin therapy have their
information sent to Anti-coagulation Clinic, whether or not they are
attending the Clinic. Discharge letter (D1) and Warfarin chart should
be faxed to BHNFT Anti-coagulation Clinic. The fax number is 01226
434431
(x)
If patient discharged on Enoxaparin (Heparin). Information on dose,
weight, renal function, indication and duration of treatment to be
included by Doctor on discharge documentation. Nurse to supply
patient with verbal and written information on signs and symptoms of
DVT and PE and importance of seeking medical help. Also to include
information about treatment on discharge/transfer documentation.
It is the named nurses’ responsibility to arrange transport. As soon as the
discharge date has been recorded transport should be booked, this will take
the form of ambulance, medicar or private transport. If there is a delay in
discharge transport will be cancelled and re-booked.
46
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
BARNSLEY BUSINESS DELIVERY UNIT
MOUNT VERNON NURSES
DISCHARGE OF A PATIENT
LOCAL WORK INSTRUCTIONS
REF LWI 13.1(2)
(h)
It is the named nurses’ responsibility to complete the Discharge Notification
Form. Top copy will accompany the patient home, the other copy secured in
the patient’s medical notes. The discharge plan to be printed off the computer
and a copy secured in patient’s notes. NB: ensure doctor signs fit for
discharge and medical exit statement on SRU.
(i)
A detailed Doctor’s discharge letter will be sent to the patient’s GP within
14 days of discharge.
(j)
Named nurse to complete inter Hospital Infection Control Form and send with
patient for attention of District Nurse/Hospital at Home Service/staff in charge
at care home/hospital staff.
(k)
Where applicable copy and send original Tissue Viability Root Cause Analysis
(RCA) form to District Nurse on discharge.
(l)
A second Patient Property Form (PPI) is to be completed stating date of
discharge and valuables taken. Top copy (white) to patient and duplicate copy
(blue) in notes.
(m)
NST, Bartel and AMT/FRAT assessments are also completed on discharge.
(n)
All nursing records will be filed in the medical case notes of the patient and
returned to General Office (including signature reference sheet).
(o)
Patients with a DNACPR form in place must be reviewed on transfer of medical
responsibility
It is the responsibility of the named nurse to :
 Send the original DNACPR form with the patient in a clearly marked
envelope
 Photocopy form and file in the medical notes. Mark ‘Copy’ in large capital
letters and sign and date.
 Inform ambulance of DNACPR on booking and show original form to the
ambulance crew on arrival
 Document DNACPR status on D1 and inform the relevant care providers,
including GP and District Nurse
 Ensure that it is documented that the patient and / or family have been
sensitively informed of the decision by the doctor. NB: if not, the
DNACPR decision does not apply on discharge from Hospital and must
be discontinued. It will not go home with the patient and the transferring
ambulance will not be informed. Doctor to write ‘Cancelled’ across the
form, sign and date and document the decision and file form in the
medical notes.
Patients taking their own discharge
(a)
The named nurse will notify the relative/carer.
(b)
Contact the Ward Doctor or on-call doctor (if after 17.00 hours and at
weekend).
47
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
BARNSLEY BUSINESS DELIVERY UNIT
MOUNT VERNON NURSES
DISCHARGE OF A PATIENT
LOCAL WORK INSTRUCTIONS
REF LWI 13.1(2)
(c)
Contact the pharmacist (during office hours). Out of office hours, patient to
contact own GP to obtain medication.
(d)
Telephone the patient’s GP and give notification of the discharge (as soon as
possible).
(e)
The patient/relative/main carer will sign the “own discharge form”.
(f)
The named nurse will contact where appropriate:



District Nursing Service via the Communication Officer;
Hospital Social Worker or Emergency Social Work Team;
Ward Clerk on the day of discharge or first working day following
discharge;

Therapists involved in care plan.
NB: Services may be arranged for up to 14 days post discharge.
If the services are required after this period of 14 days, the patient will be re-assessed
by community staff in the community.
6.0
DOCUMENTATION:
7.0
DEFINITION:
8.0
REFERENCES:
Admission summary.
Patient Property Form (PP1).
Medical notes.
Nursing records/Integrated care pathway.
Discharge Notification Form.
D1 Discharge Form.
Ward Diary.
Ambulance Book Form.
AMT/Bartel/NST.
Anti-coagulant (yellow) book.
Do not attempt Cardiopulmonary resuscitation form.
Privacy and dignity questionnaire.
RCA – Root Cause Analysis
SRU – Stroke Rehabilitation Unit.
NST – Nutritional screening tool.
DNACPR – Do not attempt cardiopulmonary
resuscitation.
TVA – Tissue viability assessment.
AMT – Abbreviated mental test.
FRAT – Fall Risk Assessment Tool
DVT – Deep Vein Thrombosis
PE - Pulmonary Embolism
BHNFT – Barnsley Hospital NHS Foundation Trust
CWI 1.1 Administration of Medicines
CW1 1.25 Oral Anticoagulant Therapy Clinical
Procedures Manual
48
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
BARNSLEY BUSINESS DELIVERY UNIT
MOUNT VERNON NURSES
DISCHARGE OF A PATIENT
9.0
FURTHER READING:
LOCAL WORK INSTRUCTIONS
REF LWI 13.1(2)
NHS National Patient Safety Agency (NPSA) Rapid
Response Report (NSPA/2010/RRR014 30 July
2010) ‘Reducing treatment errors with low molecular
weight heparins’
NHS National Institute for Health and Clinical
Excellence – Venous Thromboembolism reducing
the Risk January 2010. NICE Clinical Guidance 92.
Do Not Attempt Cardiopulmonary Resuscitation
Policy (DNACPR) October 2009.
Do Not Attempt Cardiopulmonary Resuscitation
(DNACPR) Guidance form.
49
Appendix 9
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
BARNSLEY BUSINESS DELIVERY UNIT
MOUNT VERNON NURSES
TRANSFER OF A PATIENT TO ANY OTHER
HOSPITAL
LOCAL WORK INSTRUCTIONS
REF LWI 13.1(17)
1.0
APPLICABLE TO:
Mount Vernon Nurses.
Doctor.
2.0
PERSONNEL:
Registered Nurses.
3.0
RISK FACTORS:
Disruption of patients’ care due to lack of
information.
4.0
PURPOSE:
To transfer patient effectively to any other
hospital.
5.0
PROCEDURE:
EMERGENCY TRANSFER
Within office hours (09:00 hours to 17:00 hours)
Registered Nurse to book ambulance by ringing Ambulance Service on 01924 584909,
using ambulance priority flow chart.
Out of office Hours
Registered Nurse to book ambulance by ringing Ambulance service on Tel: 01924
584932 using ambulance priority flow chart.
1. Request Paramedic assistant (if available send a nurse to escort)
2. Wherever possible the Registered Nurse liaises with patient and relatives
regarding impending transfer
3. Wherever possible the Registered Nurse liaises and informs other
hospital/department of transfer of patient and informs staff of infection status of
patient
4. Send original DNACPR form with patient and make ambulance staff aware of it
5. Send medical notes, X-rays, nursing records and safeguarding information and
treatment sheets with patient.
6. Inform of transfer:
-
Duty Officer
Doctor/Consultant
Patient’s relatives/carers
Multi-Disciplinary Team
Ward Clerk
50
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
BARNSLEY BUSINESS DELIVERY UNIT
MOUNT VERNON NURSES
LOCAL WORK INSTRUCTIONS
TRANSFER OF A PATIENT TO ANY OTHER
HOSPITAL
REF LWI 13.1(17)
ROUTINE TRANSFER
Within office hours (09:00 hours to 17:00 hours)
Registered Nurse/Ward Clerk to book ambulance by ringing ambulance service on Tel:
01924 584909, using ambulance priority flow chart
Out of office hours
Registered Nurse to book ambulance by ringing ambulance service on Tel: 01924
584982 using ambulance priority flow chart.
Arrange Nurse to escort patient during transfer (if available).
Wherever possible the Registered Nurse liaises with patient and relatives regarding
impending transfer.
Wherever possible the Registered Nurse liaises and informs other hospital/department
of transfer of patient and informs staff of infection status of patient.
Registered Nurse completes relevant forms:- Discharge Notification Form (top copy
with patient – file other copy with notes) and Inter Hospital Infection Control Form).
Send copy of admission summary/admission view and DNACPR form (if in place)
DNACPR form to be copied, original to go with patient, copy to be filed in medical
notes.
If routine transfer photocopy relevant medical notes and treatment sheet and send with
patient on transfer, also any safeguarding information if relevant.
A second Patient Property Form (PP1) to be completed stating date of transfer and
valuables taken. Top copy to patient (white) and duplicate copy (blue) in notes.
6.0
7.0
8.0
9.0
Inform of transfer:
- Ward Clerk
- Multi-Disciplinary Team
- Doctor/Consultant
- Patient’s relatives/carers
DOCUMENTATION:
Do Not Attempt Cardio Pulmonary Resuscitation Form
Inter Hospital Infection Control Form.
Nursing Records.
Medical Notes.
Discharge Notification form (PP1).
Admission Summary.
Admission view.
DEFINITION:
REFERNECES:
FURTHER READING:
Nil.
Ambulance priority flowchart.
LWI 13.1 (11) Ambulance Service
51
Appendix 10
Version Control Sheet
Discharge and Clinical Handover of service users
(including leave of absence for informal service users)
Policy
This sheet should provide a history of previous versions of the policy and changes made
Version
Date
Author
Status
Comment / changes
Version 1
October
2008
Steve Taylor
Final
Reviewed July 2010
Version 2
July 2010
Phil Tordoff
Draft
Amended following consultation
Version 2.1
October
2010
Phil Tordoff
Final
Review Date October 2010
Version 3
September
2102
Phil Tordoff
Julie Fleetwood
Draft
Policy title changed to
Discharge and Clinical Handover
of service users (including leave
of absence for informal service
users). For consultation. Policy
merged to cover all BDU’s
Version 3.1
November
2012
Phil Tordoff
Julie Fleetwood
Final
Following consultation of Ver 3
52