3 page referrals/discharge summaries

Specialties LTC Directors

Published

Specializes in Gerontology, Med surg, Home Health.

My nurses think they don't have to do a 3 page referral, what some call a discharge summary, if the resident is not going to have services when they get home since they think the information is only for the VNA or whoever the home care agency is. I maintain that EVERYONE who is discharging to home needs the information. These nurses were also told that 'regular' nurses can't write a new index in the narcotic book, and it's a regulation that licensed people chart BMs on the MAR (so you can see what I'm up against).

What do all y'all do?

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Specializes in Geriatrics, WCC.

For someone discharging to home without services w send a double sided page with a list of instructions and medications. when they go home with services, we fax orders over to the home care agency but, still send home a list of instructions with the resident.

Not sure what you mean by "regular" nurses but, any of our nurses will enter a new narc into the registry book. And, our CNA's are the ones who chart the BM's.

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My nurses think they don't have to do a 3 page referral, what some call a discharge summary, if the resident is not going to have services when they get home since they think the information is only for the VNA or whoever the home care agency is. I maintain that EVERYONE who is discharging to home needs the information. These nurses were also told that 'regular' nurses can't write a new index in the narcotic book, and it's a regulation that licensed people chart BMs on the MAR (so you can see what I'm up against).

What do all y'all do?

it takes two nurses to reindex....basically it is doing a whole narc count over....

why are bm's on the med sheet? that is a pain in the butt...pun intended.....and i had an aide tell me once they had inquired about doing that and they were told they werent supposed to be touching the MAR.....

i am not sure about the 3 page dishcharge thing......dont think i have seen persons do that if no services....but some other form needs to be done then, to document that instuctions were given.....

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Specializes in acute care and geriatric.

You know what, even if they disagree with you, you are the DON, so your standards hold. It really doesn't matter what other facilities do, we do 3page referrals on all discharges, the aides document BM's but if its wrong, the nurses are held responsible so its under the nurses guidance. and opening a new index in the controlled substances book are done by and signed by 2 nurses.

If YOU demand discharge summaries on ALL discharges- so be it!!!

You set the policy on the Narc book and documenting BM's. Just write up a new policy and enforce it.

After all it will be your u-know-what on the line if its done wrong.

Sounds like they are giving you a hard time on the small stuff,

Good Luck!

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