Nursing Facility Discharge-Day Management Note

Date/Time Authored: [Date and time authored]

Effective Discharge Date/Time: [Planned or actual discharge date and time]

Patient Name: [Full name]

DOB: [Date of birth]

MRN: [Medical record number]

Facility/Unit: [SNF name and unit]

Attending of Record: [Attending clinician name and credentials]

Author Name/Credentials/Role: [Author name, credentials, role]

Discharge Disposition: [home / ALF / LTC / hospital transfer / hospice / other] (If unknown, document as "Unknown at time of discharge; pending confirmation.")

Receiving Clinician/Agency: [Name, organization, phone, fax] (If unknown, document as "Unknown at time of discharge; pending confirmation.")

Discharge Summary

[2–4 sentence plain-language summary] (State where the patient is going and with whom; include a stability statement explaining why discharge is safe today; name the highest-risk active issues requiring immediate vigilance; list headline services arranged and key follow-up timeframes.)

Reason for Stay and Facility Course

[Narrative summary of SNF indication and course] (Include reason for SNF admission; key diagnoses managed or newly identified; pertinent results influencing ongoing care; therapy course from baseline to discharge with milestones and remaining limitations; complications or events with dates for major turning points.)

Clinical Status at Discharge

(Include only domains relevant to the patient's conditions. Omit domains that do not apply. If information is clinically important but unavailable, document as "Unknown" and specify who will verify.)

Vitals/Stability: [Last vital signs with date/time; 24-hour range if unstable; oxygen requirements]

Focused Exam/Assessment: [Targeted exam findings for active problems]

Cognition/Behavior: [Orientation; decision-making capacity; safety awareness; delirium status]

Functional Status: [Ambulation level and device; transfer assistance; ADL status; fall risk and mitigation]

Nutrition/Swallowing: [Diet texture/consistency; supplements; aspiration precautions]

Skin/Wounds: [For each wound: location, type/stage, size, most recent treatment, dressing frequency, supplies needed, follow-up plan]

Lines/Tubes/Devices: [Type, site, date placed, purpose, care instructions, removal plan]

Infection Control: [Isolation precautions relevant post-discharge; organism; expected duration]

Code Status: [Current code status; POLST/MOLST presence; surrogate decision-maker] (If unclear, document as "Unknown" and specify who will verify before discharge.)

Active Problems and Discharge Plan

(List problems in descending order of acuity/risk.)

• [Problem name] — [resolved / improving / stable / unstable]

  • What was done: [Key diagnostics, treatments, consultations, response]
  • What continues: [Medications, monitoring parameters, restrictions, home protocols]
  • Follow-up: [Clinician/service; timeframe; specific labs or parameters to monitor]
  • Red flags: [Signs/symptoms prompting urgent contact or ED visit]
• (Repeat for each additional active problem.)

Medication Reconciliation

Allergies/Intolerances: [Allergen — reaction type and severity]

Discharge Medication List: (Attribute source: per MAR, per patient report, per caregiver.)

• [Medication name] — [dose, route, frequency] — [indication] — [Continue / New / Dose changed]
• (Add additional medications as separate items.)

Medication Changes During Stay: [Medications started, stopped, or changed with brief rationale for high-impact changes such as anticoagulants, insulin, opioids, antipsychotics, diuretics]

High-Risk Medication Plans: (Include only applicable categories.)

• Anticoagulants: [Agent/dose; monitoring plan; bleeding precautions; who monitors]
• Insulin/Secretagogues: [Dosing; glucose targets; hypoglycemia plan; supplies provided]
• Opioids/Sedatives: [Duration; taper plan; bowel regimen; fall precautions; safe storage]

Medication Access: [How prescriptions sent; pharmacy name/phone; confirmation patient has medications or plan to obtain within 24 hours] (If OTC/supplements not verified, note this and instruct to bring bottles to next visit.)

Pending Tests and Results Follow-Up

• [Test name and collection date] — [Clinical decision dependent on result] — [Accountable clinician] — [How/when patient will be notified]
• (Add additional pending items as needed.)

(If no tests pending, state: "Pending tests: None.")

Follow-Up Appointments and Monitoring

• Primary Care: [Timeframe; scheduled date/time or who will schedule by when; purpose]
• Specialists: [Service; timeframe; scheduled status; purpose]
• Therapies: [PT/OT/ST — frequency; home vs. outpatient; start date]
• Labs/Imaging: [What to obtain; when; who reviews; action thresholds]

Services Arranged

• Home Health: [Agency name; disciplines ordered; contact information; start date]
• DME/Equipment: [Items ordered; vendor; delivery date; training needs]
• Wound Care Supplies: [Supply list; dressing schedule; reorder plan]
• Infusion/IV Therapy: [Line type; medication/dose/frequency; lab monitoring; nurse visit schedule]
• Transportation: [Arrangements for appointments; contingency if not confirmed]

(If a referral is pending acceptance, document status and contingency plan.)

Patient and Caregiver Education

Topics Covered: [Diagnosis; medication changes; warning signs and return precautions; diet and activity; wound care if applicable; who to call for urgent vs. non-urgent issues]

Recipients: [Patient / Caregiver name and relationship]

Understanding Assessment: [Teach-back used; skills demonstrated; remaining barriers and plan to address]

Communication and Records Transfer

Documents Sent: [Discharge summary; medication list; wound/therapy orders; recent labs]

Recipients: [Receiving provider/agency; patient/caregiver]

Method: [EHR / fax / printed / HIE] — [Date/time if known]