Discharge from continuous or day hospitalisation at Panciu Town Hospital
- Reference documents
- Law No. 46/2003 on patients' rights
- Law No. 95/2006 on healthcare reform
- Order 600/2018 approving the Code of Internal Managerial Control for public entities
- Order 600/2018 approving the Code of Internal Managerial Control for public entities
- Ministry of Health Order No. 446/2017 approving the procedures, standards and methodology for hospital assessment and accreditation
- Government Decision No. 521/2023, as amended, approving the service packages and the Framework Contract governing the conditions for providing medical care, medicines and medical devices, assisted technologies and devices within the social health insurance system for 2024 – 2025
- In accordance with the Order of the Minister of Health and of the President of the National Health Insurance House, Ministry of Health Order No. 3/2024 remains valid throughout the period of validity of Order of the Minister of Health and of the President of the National Health Insurance House No. 1,857/441/2023 approving the Methodological Rules for applying Government Decision No. 521/2023 approving the service packages and the Framework Contract governing the conditions for providing medical care, medicines and medical devices within the social health insurance system, as subsequently amended and supplemented. (Under art. 2 of Ministry of Health Order No. 3/2024, in force from 26 January 2024) for 2024 – 2025
- Internal Regulations
- General Information
Depending on the course of the patient's illness, the attending doctor will set the discharge date, which will be communicated to the patient or, in certain situations, to their relative, a day in advance or at the latest on the morning of the discharge day.
Discharge takes place after 12.00; the duty nurse will hand the patient all medical documents and their identity document, and the healthcare assistant will return their belongings.
The attending doctor is responsible for the correct completion of the FOCG/FSZ in all the boxes provided in the standard form; this is mandatory for the hospital's reporting and for validation of the case in the SNSPMS-CAS VN circuit. Surgical procedures must be recorded, together with all concomitant or subsequent surgical interventions; the operative protocol must likewise be recorded in the medical record and in the Register of Operative Protocols within the first 12 hours after the intervention; the course of the illness and specific treatment instructions must be recorded daily; the discharge summary must be recorded and entered into the IT system to automatically generate the electronic medical letter, the discharge note and the statement of costs. On the day of discharge the patient is removed from the daily catering list.
At the end of treatment, patients are discharged on the basis of the hospital discharge note drawn up by the attending doctor, with the approval of the ward chief physician or of the doctor providing specialist coordination.
On discharge the patient will receive the hospital discharge note together with the medical letter; the patient will also receive the necessary information about their condition and the medical treatment required, including information about the possible onset or worsening of signs or symptoms.
The patient may leave the hospital on request, after having been informed beforehand of the possible consequences for their health. These are recorded in the medical record under the signature of the patient and the doctor.
Among the activities carried out on the patient's discharge:
- The attending doctor establishes the discharge diagnoses, performs the DRG coding and codes the procedures carried out – medical record – and states the patient's condition on discharge – cured, improved, unchanged.
- Coding by the nurse of the procedures performed (medication administration, sample collection, dressings, monitoring, etc.) – medical record.
- Recording by the nurse with registrar/data operator duties, in the dedicated application, of the data from the medical record – primary diagnosis , secondary diagnoses, procedures, paraclinical investigations, discharge summary – correctly and completely.
- The attending doctor completes the discharge note and the medical letter, which will reach the family doctor.
- The discharge note and the medical letter are completed in two copies; one is attached to the medical record and the other is handed to the patient.
- The attending doctor will determine and record the following in the discharge note and the medical letter:
- Discharge diagnosis
- The patient's condition on discharge
- The medical treatment to be followed
- Guidance on diet and lifestyle
- Medical check-up date
- Number of sick leave days
- Where a patient is discharged at their own request, the risks they are exposing themselves to are explained to them. The attending doctor records the patient's discharge request in the medical record, and the patient is asked to sign that they requested the discharge.
Discharge may take place at the request of the patient or their relatives; in both cases this is recorded in the medical record with the requester's signature.
- The documents issued to the patient on discharge:
- Discharge note
- Medical letter
- Sick leave certificate (if applicable)
- Medical certificate (if applicable)
- Medical prescription
- Statement of expenses for the medical services received
- The attending doctor completes all the documents concerning the patient's discharge, signs and stamps them, and the head of unit checks that they have been completed in full and correctly, after which they countersign and stamp the discharge documents.
The ward/duty nurse, where appropriate (on the doctor's instruction), informs the family of an immobile patient about the discharge.
Closing the care record
The national health card will be mandatory on discharge from hospital for the electronic signing of the medical services provided during hospitalisation.
The nurse with registrar duties (the person designated to record patient data electronically) will:
- Drafts and prints the patient's discharge note
- Stamps the patient's discharge note
- Completes the FOCG/FSZ electronically with the related procedures
The healthcare assistant/cleaner will:
- Accompanies the patient from the ward to the hospital exit if necessary.
For patients considered non-transportable, discharge will be carried out by ambulance.
