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Discussion

Documentation for Readmission

Since my facility is not clear on this, i just want to ask; if a patient is readmitted on the same day, do we continue with our documentation as continuity of care, or do we start all over again (all the admission process,. initial assessments/ risk identifications, etc) since the patient was already been discharge and was given discharge instructions? Appreciate your reply guys...

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    • Featured Replies

    That's usually facility specific, things like medical history shouldn't have to be completely redone whether they are readmitted the same day or 10 years later, just updated. The risk assessments and that sort of thing might as well be done again since they are quite possiblly different than at the time of their previous admission.

    The bigger issue though is why is the patient being readmitted the same day they were discharged?

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    • Experts

    I don't know, but I bet the answer will be related to payment concerns. I'd ask my Charge RN and financial services. If it will be billed as two separate episodes then a whole readmit will probably be needed. But there could be a financial regulation that would group the 2 admits as one billable issue since it is within 24 hours. Actually I'm sure that your answer will be found not in nursing but in finance.

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    We start over again. Who is to say the patient did not do something in that time time frame that could impact their current state of health such as shooting up! If they did not do something like that,a condition they have may have worsened and their baseline may be different now. The healthcare facility had a break in the care and the plan of care should reflect that fact.

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    I always love the AMA---->re-admit the same day. We better not get dinged by Medicare for that one....

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    In the ED if we completed their discharge, we treat it as two separate visits, even if they never actually made it out of the parking lot.

    Many's the time I've wished "Are you planning on staging a pseudoseizure in the hall on your way out? If so please let me know so I don't close out your chart," was an acceptable question during discharge teaching.

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