Discharge Planning by : Abdul Holik Subaeri, M.Pd.

Discharge Planning is a process whereby the patient starts

receiving health services followed by continuity of care both in
the healing process and in maintaining his health status until
the patient feels ready to return to his environment. Discharge
Planning shows several formal processes that involve a team or
have the responsibility to manage the transfer of a group of
people to another group (RCP, 2001). The nurse is a member of
the Discharge Planner team, and as a discharge planner the
nurse examines each patient by collecting and using related
data to identify actual and potential problems, determine goals
with or with the patient and family, provide special actions to
teach and assess individually in maintain or restore the
patient's condition optimally and evaluate the continuity of
nursing care. It is the nurse's endeavor for the benefit of the
patient to prevent and improve the patient's health condition,
and as a member of the health team, the nurse collaborates
with other teams to plan, take action, coordinate and facilitate
total care and also help patients achieve their main goal in
improving their health status.

Purpose of Discharge Planning Is to improve the continuity of

care, improve the quality of care and maximize the benefits of
health care resources. Discharge Planning can reduce patient
care days, prevent recurrence, improve the development of the
patient's health condition reduce the burden of care on the
family. This can be done through Discharge Planning (Naylor,
1990). According to Mamon et al (1992), giving discharge
planning can improve patient progress, help patients achieve an
optimum quality of life before being discharged, some studies
have even stated that discharge planning has an important
effect in reducing disease complications, preventing recurrence
and reducing mortality and morbidity (Leimnetzer et al, 1993:
Hester, 1996)

A Discharge Planners are in charge of planning, coordinating

and monitoring and providing follow-up treatment actions and
processes (Powell, 1996). This discharge planning places nurses
in an important position in the patient treatment process and in
the hospital discharge planner team, the knowledge and
abilities of nurses in the nursing process can provide continuity
of care through the discharge planning process (Naylor, 1990).
The nurse is considered as someone who has more competence
and has expertise in carrying out accurate assessments,
managing and having good communication and being aware of
every condition in society. (Harper, 1998).

Advantages of Discharge Planning

For Patients:
- Can meet patient needs
- He/ she feels that he is part of the maintenance process as an
active part and not a powerless object.
- Recognizing his right to be met all his needs
- Feel comfortable to continue treatment and get support
before problems arise.
- Can choose the treatment procedure
- Understand what happened to him and know who he can
contact.

For Nurses:
- Feel that his skills are accepted and can be used
- Receive key information every time
- Understand its role in the system
- Can develop skills in new procedures
- Have the opportunity to work in different settings and in
different ways.
- Work in a system effectively.

Discharge Planning Components

1. Schedule controls and explain the importance of exercising
control.
2. Home care
1. Includes teaching or health education regarding: diet,
mobilization, control time and control sites. Learning provision
is adjusted to the level of understanding of the patient and
family. regarding the care while the patient is at home later.
2. Medicines that are still being taken and the amount
3. Patients who are going home will explain the medicines that
are still being taken, the dosage, the method of administration,
and the exact time to take the medicine.
4. Discontinued drugs
5. Even though there are medicines that the patient does not
take anymore, they are still brought to the patient.
6. The results of the examination
The results of the external examination before MRS and the
results of the examination during the MRS are brought to the
patient when they go home
7. Letters such as: sickness certificate, control letter and others.

Nursing Actions at Discharge Planning Time

Treatment measures given at discharge planning include:
a. Education (education, education, reorientation) of health
education is expected to reduce relapse rates and improve
patient awareness.
b. Gradual return program
The aim is to train patients to return to the family and
community environment, among other things, what patients
should do in the hospital, what families should do.
c. Reference
The integrity of health services must have a direct relationship
between community care and hospitals so that they can know
the progress of patients at home.
Patient discharge type
1. Conditional discharge (going home temporarily or on leave),
this is done if the patient's condition is good there is no
compilation. Patients are temporarily treated at home but
there must be supervision from the nearest hospital or public
health centre.
2. Absolute discharge (absolute or permanent discharge) this
method is the end of the patient's relationship with the
hospital. However, if the patient needs to be treated again, the
treatment procedure can be carried out again.
3. Judical discharge (forced discharge), this condition allows the
patient to go home even though his health condition does not
allow him to go home, but the patient must be monitored in
collaboration with the nearest health center nurse.

Points to Pay Attention to in Discharge Planning

Even though the patient has been discharged, it is important
that the patient and family know what has been done and how
they can continue to improve the patient's health status. In
addition, the discharge summary can be submitted by the
practitioner / home care nurse and possibly sent to the primary
doctor / doctor involved for inclusion in the institution's records
to improve continuity of care with continuous work towards
goals and monitoring of changing needs (Doenges &
Moorhouse , 2000).
Discharge Planning must be adjusted to:
1. Client needs, the availability of a health team
2. Starting from the beginning of admission to the hospital
3. Compiled by a team