CC.4.1 The follow-up process provides for continuing care to meet the patient’s needs.

CC.4.1.1 The patient is informed in a timely manner of the need for planning for discharge or transfer to another organization or level of care.

CC.5 Appropriate information related to the care and services provided is exchanged when a patient is accepted, referred, transferred, discontinued service, or discharged to receive further care or services.

CC.3 The hospital provides for continuity over time among the care and services provided to a patient.

(Patient Safety Goal) Develop a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list.

(Patient Safety Goal) A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization.

CMS 7th SOW and JCAHO—Heart Failure: Percent of Patients Discharged Home with Written Discharge Instructions or Educational Material (Centers for Medicare and Medicaid Services, 2002)

Heart failure patients with documentation that they or their caregivers were given written discharge instructions or other educational materials addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.

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