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Prescriptions and Medications

October 14th, 2016

The discharge instructions must include any prescriptions and over-the counter medications, including the name of the drug, indication, and dosage. Any significant risks and side effects must be disclosed. The discharge instructions must include reconciliation of all discharge medication with the pre-hospital medications.

The written discharge instructions must include follow-up care, pending tests, planned additional testing, and contact information. The contact information, including phone numbers, must be included for any physician, provider or supplier who is going to provide follow-up care or provide supplies or equipment.

It is important to note that a copy of the discharge instructions and discharge summary must be sent to the practitioner or physician who is responsible for the follow-up care within 48 hours. Physicians or LIPs who discharge the patient may need to immediate dictate the discharge summary. Health Information Management will need to get it transcribed and ensure it gets into the hands of the follow up practitioner within this 48 hour time frame. Pending test results must be sent to the provider within 24 hour of their availability. This will definitely create a challenge for some patients.