Discharge Plan

Collaboration for Improving Outcomes – Discharge Plan

Description: The baccalaureate graduate nurse will conduct a health history to identify

current and future health problems.

Course Competencies: 2) Develop a holistic case management plan for a specified disease or

population that incorporates the role of insurance, health care finance, and utilization of

community resources. 4) Coordinate the care of individuals across the lifespan utilizing

principles and knowledge of interdisciplinary models of care delivery and case management.

QSEN Competencies: 1) Patient-Centered Care 2) Teamwork and Collaboration 3) Evidence-

Based Practice

BSN Essential VII

Area Gold

Mastery

Silver

Proficient

Bronze

Acceptable

Acceptable

Mastery not

Demonstrated

Assessment

• General Information

• Current Medications

• Activity of Daily Living

• Patient Support System

• Medical Follow-up

• Financial Summary

Completes all

sections of the

assessment

Completes half

of the elements

of the

assessment.

Completes

less than half

of the

elements of

the

assessment

Elements are

superficially

addressed or

are missing.

Diagnosis/Plan

• Priority

• Nursing Diagnosis

• Client Outcomes/Goals

Completes all

elements of the

diagnosis/plan

Completes half

of the elements

of the

diagnosis/plan

Completes

less than half

of the

elements of

the

diagnosis/plan

Elements are

superficially

addressed or

are missing.

Education Needs

• Need

• Method

• Evaluation

Completes all

elements of the

education

needs

Completes half

of the elements

of the

education

needs

Completes

less than half

of the

elements of

the education

needs

Elements are

superficially

addressed or

are missing.

Financial Worksheet

• Future Medical Care

-routine

-specialty

-Tx

interventions

• Medication Needs

• Supplies

• Diagnostic Testing

• Future Adjunctive Tx

• Medical Equipment

• Transportation

• Home Furnishings &

Adaptations

• Potential Complications

• Financial Summary

Completes all

elements of the

financial

worksheet

Completes half

of the elements

of the financial

worksheet

Completes

less than half

of the

elements of

the financial

worksheet

Elements are

superficially

addressed or

are missing.

Reflection and

Conclusion

Interprets the

complete

format and

develops a

conclusion for

the plan of care

Reviews the

format and

does not fully

develop a

conclusion for

the plan of care

Defines the

format and

does not

present a

conclusion

Does not

provide an

interpretation

of the format

and/or no

conclusion for

plan of care.

APA, Grammar,

Spelling, and

Punctuation

No errors in

APA, Spelling,

and

Punctuation.

One to three

errors in APA,

Spelling, and

Punctuation.

Four to six

errors in

APA,

Spelling, and

Punctuation.

Seven or more

errors in APA,

Spelling, and

Punctuation.

References Provides two or

more

references.

Provides two

references.

Provides one

references.

Provides no

references.