A resident leaving your building, whether for a hospital, another facility or home, is one of the riskiest moments in care. Information that does not travel with the resident, or arrives late or incomplete, leads to repeated questions, medication errors and avoidable returns to the hospital. The receiving team cannot act on what they do not have.
Much of this comes down to workflow, not technology. Your electronic health record can hold and send the right documents, but only if the team agrees on what goes out and who prepares it. Checklists make that agreement visible. The ideas below apply in general terms to PointClickCare and other long-term care systems, so adapt them to the tools and forms your facility uses.
Decide who is responsible for each part of an outbound packet.
Nursing: current clinical status, recent vital signs, wounds, mobility and treatments.
Medication management: the current medication list, last administered doses and allergies.
Social services: contacts, advance directives, code status documentation and payer information.
Medical records or the business office: registration details, insurance and face sheet.
Physician or nurse practitioner: orders and the clinical summary.
One person, often a unit manager or the charge nurse, should confirm that the packet is complete before the resident leaves.
Time is short, so keep this list on one page and practice it.
Resident identification and a current face sheet, with correct contact numbers.
Reason for transfer and a brief description of the change in condition.
Most recent vital signs and relevant observations.
Current medication list, last administration times and known allergies.
Code status, advance directive and any guardian or health care proxy information.
Recent labs or imaging relevant to the problem, if available.
Name and phone number of a nurse who can answer questions.
Name of the family contact notified, and when.
Call the receiving unit with a verbal report, and note the time and the person who took the call.
Planned discharges allow more thorough preparation.
Confirmed discharge date, destination and transportation.
Updated medication list with clear instructions, and review of any changes with the resident or family.
Prescriptions and supplies, such as dressings or equipment, arranged in advance.
Follow-up appointments scheduled, with dates and contact numbers.
Summary of the stay, including therapy progress and remaining needs.
Instructions for diet, activity, warning signs and whom to call.
Referrals for home health or outpatient services, with confirmation that they were received.
Documentation that the resident or representative received and understood the instructions.
Where your system allows, build discharge and transfer steps into standard assessments, tasks or care-plan items so they appear automatically when a resident is flagged for departure. Consider:
Using standard, facility-approved forms rather than free text, so every packet looks the same.
Setting reminders for tasks with deadlines, such as medication reconciliation.
Making key fields required where practical, so critical items cannot be skipped.
Confirming who has permission to finalize and send outbound documents.
Check with your EHR vendor or administrator about the best way to configure these, rather than assuming a particular feature exists.
Use secure methods to send information to the receiving party, such as an approved electronic exchange or a secure fax or portal, rather than personal email or text. Send only what is needed for treatment, and confirm that the recipient's fax number or address is correct before sending. HIPAA permits sharing for treatment purposes, but it still expects reasonable safeguards.
A handoff is not finished when the resident leaves.
Confirm arrival and that the receiving team has the documents.
If the resident returns, ensure that hospital discharge records are obtained and reviewed, and that medications are reconciled promptly.
Track transfers: date, reason, destination, and whether the packet was complete.
Once a month, look at a sample of recent transfers. Were any items missing? Did the receiving team call with questions? Use what you find to refine the checklist and train staff. Over time, the data also shows patterns, such as the most common reasons for transfer or the days when packets are least complete.
UnityCare IT helps long-term care providers review documentation workflows, secure the systems used for sending records and train staff on consistent processes. Cleaner handoffs begin with a simple checklist everyone follows.
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