Patient Instructions and Transfer Records Documentation

It is vital that the patient be given clear and concise ­instructions upon discharge, so the recovery progress begun in the hospital continues. Ideally, patient instructions are communicated verbally and in writing. The healthcare professional who delivers the instructions to the patient or caregiver should sign the health record to indicate that he or she has issued them. In addition, the person receiving the instructions should sign to verify that he or she has received and understands them. A copy of these instructions should be filed in the health record.

When someone other than the patient assumes responsibility for the patient’s aftercare, the record should indicate the instructions were given to the responsible party. Documentation of patient education may be accomplished by using formats that prompt the person providing instruction to cover important information.

When a patient is being transferred from the acute setting to another healthcare organization, a transfer record may be initiated. This documentation is also called a referral form. A brief review of the patient’s acute stay along with current status, discharge and transfer orders, and any additional instructions will be noted. Social service and nursing personnel often complete portions of the transfer record.