Progress Notes: Discharge Procedure for Mrs. Mavis Lynch

QUESTION

Acrobat Make a PROGRESS NOTES of this scenario. To commence the discharge procedure for the client. Complete the discharge procedure including: collection of discharge planning data . Identify hindrances to discharge process and address them appropriately . Identify community support services and resources to assist in discharge planning Check discharge requirement of facility and complete them Pharmacy Discharge education, Communications and hand-overs Transport requirements Financial requirements Discharge documentation Scenario Mrs Mavis Lynch is an 82-year old resident of your facility for the last 10 years. Mavis has a medical history of type 2 diabetes mellitus, hypertension, recurrent falls, multiple skin teras, chronic wound on right leg and mild cognitive impairment. On the nursing assessment, Mavis is pleasantly confused vital signs are stable, has very frail dry paper-like skin and high risk for falls and skin tears. Mavis has 3rd daily dressing for the chronic diabetic wound on her right leg and has GP reviewing her wound, blood glucose levels and hypertension management monthly. Current care plan of Mavis is provided in appendix. Mavis has an incredibly supportive family. Her husband visits her daily during meal times and daughter visit every weekend. Recently facility has been informed that Mrs Lynch has suffered from a stroke with hemiparesis and has acquired a place in another aged care facility where Mrs Lynch would also be moved to cater for family inclusively and preferences. Focus 96 words English (Australia)

ANSWER

Progress Notes: Discharge Procedure for Mrs. Mavis Lynch

Date: [Current Date]
Client: Mrs. Mavis Lynch
Age: 82 years
Medical History: Type 2 diabetes mellitus, hypertension, recurrent falls, chronic wound on right leg, mild cognitive impairment

Discharge Planning Data Collection:
Reviewed Mrs. Lynch’s medical history, including diabetes, hypertension, falls, wound management, and cognitive impairment.
Noted that Mrs. Lynch has an incredibly supportive family, with her husband and daughter visiting regularly.
Assessed her recent stroke with hemiparesis and the need for specialized care at another aged care facility.

Identified Hindrances and Addressed:
Recognized that Mrs. Lynch’s chronic wound and hemiparesis require specialized care.
Addressed potential hindrances by arranging a seamless transition to the new facility catering to her needs.

Community Support Services:
Identified available community resources for stroke recovery, wound care, and cognitive impairment management.
Collaborated with the new facility to ensure continuity of care and support services.

Facility Discharge Requirements:
Checked and completed all necessary facility discharge requirements, including medical records, care plans, and medication lists.

Pharmacy Discharge:
Ensured medications are up-to-date and properly labeled for transfer to the new facility.
Coordinated with the pharmacy to arrange timely delivery of required medications.

Discharge Education:
Provided comprehensive discharge education to Mrs. Lynch’s family and the new facility staff regarding her medical history, wound care, medication regimen, and fall prevention strategies.

Communications and Handovers:
Conducted thorough handover meetings with the new facility’s medical team to discuss Mrs. Lynch’s medical condition, care plan, and preferences.
Communicated effectively with Mrs. Lynch’s family, her husband, and daughter, about the transition and any changes in care requirements.

Transport Requirements:
Arranged appropriate transportation with the new facility, ensuring Mrs. Lynch’s safety and comfort during the transfer.

Financial Requirements:
Assisted in facilitating any necessary financial arrangements or insurance paperwork for the transfer and new facility admission.

Discharge Documentation:
Prepared and organized all required discharge documents, including medical records, care plans, medication lists, and any relevant medical reports.

Conclusion

The discharge procedure for Mrs. Mavis Lynch has been meticulously planned and executed to ensure a smooth transition to the new aged care facility. The focus has been on addressing her medical needs, coordinating with the new facility, and providing comprehensive support to her family during this transition. The collaborative effort between the healthcare team, Mrs. Lynch’s family, and the new facility aims to ensure her well-being and comfort in her new environment.