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Release Notes:
Data Element
Version 2010B

Data Element Name: Discharge Instructions Address Follow-up
Collected For: HF-1,
Definition:Written discharge instructions or other documentation of educational material given to patient/caregiver addressing follow-up with a physician/advanced practice nurse/physician assistant (physician/APN/PA) after discharge.

Suggested Data Collection Question:Did the WRITTEN discharge instructions or other documentation of educational material given to the patient/caregiver address follow-up with a physician/APN/PA after discharge?
Allowable Values:

Y    (Yes)   WRITTEN discharge instructions/educational material given to patient/caregiver address follow-up with a physician/APN/PA after discharge.

N   (No)   WRITTEN discharge instructions/educational material do not address follow-up with a physician/APN/PA or unable to determine from medical record documentation.

In order to identify the specific discharge instructions that are missing, the internal variables (discharge counter and missing flag) must be stored so calculations of rates for each instruction component can be performed.

Notes for Abstraction:
  • In the absence of explicit documentation that follow-up involves contact with a physician/APN/PA, the abstractor may infer contact with a physician/APN/PA, unless documentation suggests otherwise (e.g., BP check, laboratory work only).
  • Some hospitals use discharge instruction sheets, brochures, booklets, and teaching sheets to provide written instructions to the patient. Others use electronically formatted media such as videos, CDs, and DVDs, which are also acceptable educational materials.
    • Documentation must clearly convey that the patient was given a copy of the discharge instruction material to take home. When a discharge instruction sheet, teaching sheet, brochure, or booklet is present in the medical record and there is no documentation which clearly suggests that a copy was given to the patient/caregiver (e.g., statement on form such as “pink copy to patient”), the inference should be made that it was given IF the patient's name or the medical record number appears on the material AND hospital staff or the patient/caregiver has signed the material.
    • When a copy of the material is not included in the medical record, documentation must clearly convey that follow-up instructions are included in the material. Use only the documentation provided in the medical record itself. If material is located outside of the medical record, it should not be reviewed and used in abstraction.
    • Documentation of follow-up instructions in the educational material can take many forms.
      -Discharge nursing note which outlines the areas covered in the material such as "Heart Failure Management brochure given to pt. - addresses diet, activity, and follow-up"
      -Notation on discharge instruction sheet such as "Follow-up: Given Heart Failure Management CD"
  • Written instructions do NOT need to be given at the time of discharge. Instructions given anytime during the hospital stay are acceptable.
  • If the patient refused written discharge instructions or other documentation of educational material which addressed follow-up, select “Yes.”
  • In cases where a document provides a checkbox for this information and the checkbox is left unchecked, credit for giving written follow-up instructions to the patient/caregiver should not be taken. E.g., Checkbox on discharge instruction sheet which reads, “Follow-up: Call Dr.’s office for appointment within two weeks” is left unchecked – select “No.”
  • The caregiver is defined as the patient’s family or any other person (e.g., home health/VNA provider) who will be responsible for care of the patient after discharge.
Suggested Data Sources:
  • Discharge summary
  • Care plans/clinical pathways
  • Discharge instruction sheet
  • Discharge progress notes
  • Home health referral form
  • Nursing discharge notes
  • Teaching sheet
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • None
  • Follow-up prescribed on PRN or as needed basis
  • Follow-up noted only as Not Applicable (N/A), None, or left blank

Discharge Instructions Address Follow-up
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)