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Discharge Planning & Care Transitions Audit
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Audit of hospital discharge planning covering timely screening, patient goals and preferences, post-acute provider choice, medication reconciliation, and transfer of information under the CMS discharge planning CoP.
CMS 42 CFR 482.43IMPACT ActTJC PC.04.01.0142 CFR 482.61
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Screening & Evaluation
- Are all inpatients identified early for discharge planning needs based on a documented screening process? *
- Is a discharge planning evaluation completed by qualified personnel for patients who need it, and its results discussed with the patient or representative? *
- Does the process focus on patient goals of care and treatment preferences? *
Post-Acute Provider Choice
- For patients needing post-acute care (HHA, SNF, IRF, LTCH), is a list of available participating providers in the service area provided? *
- Are relevant quality and resource-use data on post-acute providers shared to inform patient choice? *
- Is the patient's freedom to choose among participating providers respected and documented? *
Medication Reconciliation & Instructions
- Is medication reconciliation completed at discharge and reconciled discharge medications communicated to the patient and next provider? *
- Are written discharge instructions provided in a form the patient/caregiver can understand, including warning signs and follow-up? *
Transfer of Information
- Is a discharge summary and necessary medical information sent to the receiving facility or practitioner at transfer/discharge? *
- Is a follow-up appointment or plan established, especially for high-risk patients? *
- Is the discharge plan reassessed and updated when factors affecting continuing care needs change? *
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