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Fill in Your Hospital Discharge Papers Template

The Hospital Discharge Papers form, also known as the TB 354, is a mandatory document used by healthcare providers in New York City to request approval for discharging patients with infectious tuberculosis. This form collects essential patient information, discharge details, and follow-up care plans to ensure the safety and health of the patient and the community. It is crucial for healthcare providers to complete and submit this form at least 72 hours before the planned discharge date.

Table of Contents

The Hospital Discharge Papers form, officially known as the Hospital Discharge Approval Request Form (TB 354), plays a crucial role in the safe transition of patients diagnosed with infectious tuberculosis (TB) from hospital care to their next living situation. This form is required by the New York City Department of Health and Mental Hygiene and must be completed in full before a patient can be discharged. It collects essential information about the patient, including their contact details, the discharging facility, and the planned discharge date. Additionally, it outlines the follow-up care appointments and identifies any potential barriers to treatment adherence. Laboratory results related to the patient's TB status, such as acid fast bacilli (AFB) smear results, are also documented. Treatment information, including the medications prescribed and their dosages, is critical for ensuring continuity of care. The form must be submitted at least 72 hours prior to discharge to allow for review and approval by health department officials. This process ensures that all necessary precautions are taken to protect both the patient and the community from the spread of TB.

Sample - Hospital Discharge Papers Form

NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE

BUREAU OF TUBERCULOSIS CONTROL

HOSPITAL DISCHARGE APPROVAL REQUEST FORM

Please complete this form in entirety and fax to 347-396-7579

SECTION A: Patient Contact Information

Patient name:

DOB: _______/_______/_______

yyyy

Tel. #: (1) ( ______ )_________ – ______________

(2) ( ______ )_________ – ______________

Address:

Apt.:

City:

State:

Zip:

Emergency contact name:

Relationship to patient:

Tel. #: (

)

–

SECTION B: Discharge Information

Discharging facility:

Discharging facility tel. #: (

)

–

Address:

Fl.:

City:

State:

Zip:

Patient medical record #:

Date of admission:

Planned discharged date:

yyyy

Discharged to:

☐ Home (if not the same address as above, fill in address below)

☐ Shelter

☐ Skilled nursing facility

☐ Jail/Prison

☐ Residential facility

☐ Other facility

Name of facility:

Tel. #: (

)

–

Address:

Apt./Fl.:

City:

State:

Zip:

Is patient scheduled to travel outside of NYC?

☐ Yes ☐ No If yes, specify date/destination:

SECTION C: Patient Follow-Up Appointment

Patient follow-up appointment date:

yyyy

Physician assuming care:

Tel. #: (

)

–

Cell. #: (

)

–

Address:

City:

State:

Zip:

Potential barriers to TB therapy adherence: ☐ None

☐ Adverse reactions

☐ Homelessness

☐ Physical disability (specify)

☐ Medical condition (specify)

☐ Substance use (specify)

☐ Mental disorder (specify)

☐ Other

SECTION D: Laboratory Results

Dates of three most recent

Specimen source

Acid fast bacilli (AFB) smear results

acid fast bacilli (AFB) smears

_______/_______/_______

☐ Positive Grade: ______

☐ Negative

_______/_______/_______

☐ Positive Grade: ______

☐ Negative

_______/_______/_______

☐ Positive Grade: ______

☐ Negative

SECTION E: Treatment Information

Date TB therapy initiated:

Interruption in therapy?

☐ Yes

☐ No

If yes, state the reason and duration

yyyy

of the interruption?

☐ RIF _____ mg

☐ PZA _____ mg

☐ EMB _____ mg

☐ SM _____ mg ☐ Vitamin B6 _____ mg

TB medications

☐ INH _____ mg

at discharge:

☐ Injectables (specify)

☐ Other TB meds (specify)

Frequency: ☐ Daily ☐ 2x weekly

☐ 3x weekly

☐ Other

Was a central line (i.e. PICC) inserted on the patient?

☐ Yes ☐ No

Number of days of medications supplied to patient at discharge

Patient agreed to be on DOT? ☐ Yes

☐ No

Print name of individual filling out this form:

Date:

yyyy

Name of responsible physician at the discharging facility:

License #:

Signature of responsible physician at the discharging facility:

Tel. #: (

)

–

COMPLETED BY THE HEALTH DEPARTMENT

BTBC NUMBER:

Discharge approved: ☐ Yes

☐ No

Action required before discharge:

Reviewed by:

Date:

NAME OF HEALTH OFFICER/DESIGNEE

yyyy

TB 354 (11/10)

↓ Hospital Discharge Papers PDF

File Specs

Fact Name	Details
Governing Law	The New York City Health Code, Article 11 mandates approval from the NYC Department of Health & Mental Hygiene for discharging infectious TB patients.
Submission Timeline	Health care providers must submit the Hospital Discharge Approval Request Form at least 72 hours before the planned discharge date.
Discharge Review	The Department of Health will review the form and may approve it or request additional information before discharge.
Weekend/Holiday Protocol	For weekend or holiday discharges, arrangements should be made in advance to ensure compliance with regulations.
Contact Information	Section A of the form requires the patient’s contact details, including an emergency contact's information.
Follow-Up Care	Section C mandates that the form includes the patient’s follow-up appointment date and the physician assuming care.

Hospital Discharge Papers - Usage Guidelines

Once the Hospital Discharge Papers form is completed, it should be faxed to the New York City Department of Health and Mental Hygiene at 347-396-7579. Ensure all sections are filled out accurately to avoid delays in the discharge process.

Section A: Patient Contact Information
- Enter the patient’s full name.
- Fill in the date of birth (DOB) in mm/dd/yyyy format.
- Provide two telephone numbers, including area codes.
- Complete the patient’s address, including apartment number, city, state, and zip code.
- List the emergency contact name and their relationship to the patient.
- Include the emergency contact’s telephone number.
Section B: Discharge Information
- Write the name of the discharging facility and its telephone number.
- Fill in the facility's address, including floor number, city, state, and zip code.
- Provide the patient’s medical record number.
- Enter the date of admission and planned discharge date in mm/dd/yyyy format.
- Select the discharge location from the options provided. If it’s a different address, fill in the new address.
- If applicable, indicate if the patient is scheduled to travel outside of NYC and specify the date and destination.
Section C: Patient Follow-Up Appointment
- Input the date for the follow-up appointment in mm/dd/yyyy format.
- Provide the name and contact details of the physician assuming care.
- Check any potential barriers to TB therapy adherence that apply.
Section D: Laboratory Results
- List the dates of the three most recent acid fast bacilli (AFB) smear results.
- Indicate whether each smear result was positive or negative and provide the grade if positive.
Section E: Treatment Information
- Fill in the date TB therapy was initiated in mm/dd/yyyy format.
- If there was an interruption in therapy, check "Yes" and provide the reason and duration.
- Check the boxes next to each TB medication prescribed and state the dosages.
- Specify the frequency of medication administration.
- Indicate if a central line was inserted and the number of days of medications supplied at discharge.
- State if the patient agreed to be on directly observed therapy (DOT).
Final Steps
- Print the name of the individual completing the form.
- Have the responsible physician at the discharging facility print and sign their name, along with their license number and telephone number.
- Fax the completed form to the DOHMH at 347-396-7579.

Your Questions, Answered

What is the purpose of the Hospital Discharge Papers form?

The Hospital Discharge Papers form, also known as the TB 354, is used to obtain approval from the New York City Department of Health and Mental Hygiene before discharging patients with infectious tuberculosis (TB) from the hospital. This process ensures that the patient receives appropriate follow-up care and minimizes the risk of spreading TB to others.

Who needs to complete this form?

This form must be completed by healthcare providers at the discharging facility. It requires detailed information about the patient, their treatment, and their discharge plans. This information is crucial for the health department to assess the patient's condition and ensure safe discharge.

How far in advance must the form be submitted?

The form should be submitted at least 72 hours prior to the anticipated discharge date. This timeframe allows the Department of Health to review the information and approve the discharge or request additional details if necessary.

What information is required in Section A of the form?

Section A collects the patient's contact information, including their name, date of birth, telephone numbers, and address. Additionally, it requires the name and contact information of an emergency contact, along with their relationship to the patient. Accurate information in this section is essential for follow-up care.

What should be included in Section B regarding discharge information?

In Section B, the form asks for details about the discharging facility, including its name, address, and telephone number. It also requires the patient's medical record number, admission date, planned discharge date, and the destination to which the patient will be discharged. If the patient is going to a different location, that facility's details must also be provided.

What is the significance of the follow-up appointment in Section C?

Section C emphasizes the importance of continuity of care after discharge. It requires the date of the patient's follow-up appointment and the contact information of the physician who will assume care. Identifying potential barriers to treatment adherence, such as homelessness or substance use, is also crucial for planning effective follow-up support.

What laboratory results need to be reported in Section D?

Section D requires the reporting of the three most recent acid fast bacilli (AFB) smear results. This includes the date of the specimen collection, the source, and whether the results were positive or negative. This information helps assess the patient's infectious status and informs the discharge decision.

What details are necessary in Section E regarding treatment information?

In Section E, healthcare providers must indicate when TB therapy was initiated and whether there were any interruptions in treatment. They should list all prescribed TB medications, including dosages and frequency. It is also important to note if a central line will be inserted and how many days of medication will be supplied at discharge.

What should be done if a discharge is planned for a weekend or holiday?

For weekend or holiday discharges, all arrangements should be made in advance. The written discharge plan must still be submitted to the Bureau of TB Control, but it is essential to plan ahead to ensure that the necessary reviews and approvals can be completed on time.

Where can I find more information about the TB discharge process?

For detailed guidelines on the hospital admission and discharge of TB patients, you can refer to the New York City Department of Health and Mental Hygiene’s Bureau of TB Control Policies and Protocols manual. This resource is available online and provides comprehensive information about the procedures and requirements.

Common mistakes

Incomplete Patient Information: Failing to provide complete contact information for the patient can lead to delays in processing. Ensure all fields, including the patient's name, date of birth, and contact numbers, are filled out accurately.
Missing Discharge Details: Not specifying the discharging facility or its contact information can create confusion. Include the facility's name, address, and phone number to ensure proper communication.
Neglecting Follow-Up Appointments: Omitting the follow-up appointment date and the physician's information can hinder the patient's continuity of care. Always provide this critical information to facilitate further treatment.
Laboratory Results Inaccuracy: Reporting incorrect or incomplete laboratory results can compromise patient safety. Verify all acid fast bacilli (AFB) smear results and ensure the dates are accurate.
Unclear Treatment Information: Failing to clearly state the treatment plan, including dosages and medication frequency, can lead to misunderstandings. Be precise and thorough when documenting TB medications.
Not Submitting on Time: Submitting the form less than 72 hours before the planned discharge date can result in delays. Always adhere to the submission timeline to avoid complications.

Documents used along the form

When a patient is discharged from a hospital, especially in cases involving tuberculosis (TB), several important forms and documents may accompany the Hospital Discharge Papers. Each of these documents serves a specific purpose in ensuring the patient's continuity of care and compliance with health regulations. Below is a list of additional forms that are commonly used in conjunction with the Hospital Discharge Papers.

Follow-Up Care Plan: This document outlines the patient's ongoing treatment and care after discharge. It includes details about medications, therapy sessions, and any necessary follow-up appointments with healthcare providers.
Patient Consent Form: This form indicates that the patient has agreed to the discharge plan and understands the potential risks involved. It is crucial for protecting both the patient and the healthcare provider legally.
Medication Reconciliation Form: This form lists all medications the patient was taking prior to hospitalization, along with any new prescriptions provided at discharge. It helps to prevent medication errors and ensures that the patient understands their medication regimen.
Transfer Summary: If the patient is being transferred to another facility, this document summarizes the patient's medical history, treatment received, and any specific needs. It facilitates smooth transitions between care settings.
Informed Refusal Form: If a patient refuses any part of their treatment or follow-up care, this form documents their decision. It is essential for ensuring that the healthcare provider has communicated the risks associated with the refusal.
Insurance Authorization Form: This form confirms that the patient’s insurance will cover the costs associated with their discharge and follow-up care. It is vital for avoiding unexpected medical bills.
Community Resource Referral: This document provides information about local resources available to the patient, such as support groups or housing assistance. It helps ensure that the patient has access to necessary services post-discharge.

Understanding these documents is essential for ensuring a safe and effective discharge process. Each form plays a role in protecting the patient's health and ensuring they receive the appropriate follow-up care. If you have any questions about these forms or the discharge process, it is important to reach out to healthcare providers for clarification.

Similar forms

The Hospital Discharge Summary is a document that provides an overview of a patient's hospitalization. It typically includes information such as the patient's diagnosis, treatment received, and instructions for follow-up care. Like the Hospital Discharge Papers, this summary is essential for ensuring continuity of care. Both documents serve to inform the next healthcare provider about the patient's condition and treatment history, facilitating a smooth transition from hospital to home or another care facility.

The Aftercare Instructions document is similar to the Hospital Discharge Papers in that it provides detailed guidance on the care a patient should receive after leaving the hospital. This document outlines medication regimens, follow-up appointments, and any lifestyle changes needed for recovery. Both forms aim to ensure that patients understand their post-discharge responsibilities and the steps necessary for their ongoing health management.

The Transfer of Care Form is another document comparable to the Hospital Discharge Papers. It is used when a patient is being transferred from one healthcare facility to another. This form includes vital information about the patient’s medical history, current condition, and treatment plan. Like the discharge papers, it aims to provide the receiving facility with the necessary information to continue care without interruption.

The Continuity of Care Document (CCD) is also similar to the Hospital Discharge Papers. It is a standard format for sharing patient information among healthcare providers. The CCD includes details about the patient's medical history, medications, and care plans. Both documents serve to enhance communication between healthcare providers, ensuring that everyone involved in the patient's care is informed and aligned on treatment goals.

Lastly, the Medication Reconciliation Form shares similarities with the Hospital Discharge Papers. This document lists all medications a patient is taking, including dosages and instructions. It helps prevent medication errors during transitions in care. Both forms emphasize the importance of accurate medication information to ensure patient safety and adherence to treatment plans after discharge.

Dos and Don'ts

When filling out the Hospital Discharge Papers form, there are several important actions to consider. Below is a list of things you should do, as well as things you should avoid.

Do complete all sections of the form. Ensure that every part is filled out accurately to avoid delays.
Do verify patient contact information. Double-check names, addresses, and phone numbers for correctness.
Do include emergency contact details. Provide the name and relationship of someone who can be reached in case of an emergency.
Do submit the form at least 72 hours before discharge. This allows time for review and approval by the health department.
Do check for potential barriers to therapy adherence. Identifying issues early can help in planning appropriate care.
Do keep a copy of the completed form. Having a record can be helpful for future reference.

Don’t leave any sections blank. Incomplete forms can lead to rejection or requests for additional information.
Don’t forget to include the discharge destination. Specify where the patient will be going after leaving the hospital.
Don’t ignore the follow-up appointment. Schedule and document this to ensure continuity of care.
Don’t submit the form outside of business hours without prior arrangements. Weekend and holiday discharges require advance planning.
Don’t overlook the physician’s signature. This is crucial for the form’s validity.
Don’t hesitate to ask for help if needed. If you have questions, reach out to the appropriate contacts for assistance.

Misconceptions

Understanding the Hospital Discharge Papers form is crucial for ensuring a smooth transition from hospital to home or another facility. However, there are several misconceptions that can lead to confusion. Here are eight common misconceptions about this important document:

The form is optional for patients with tuberculosis (TB). Many believe that the Hospital Discharge Approval Request Form is not mandatory. In fact, it is required by the New York City Health Code for all patients diagnosed with infectious TB before they can be discharged from a hospital.
Discharge approval can be requested on the same day as discharge. Some think that they can submit the form on the day of discharge. However, health care providers must submit the form at least 72 hours prior to the planned discharge date to allow for proper review.
Only the patient’s physician needs to fill out the form. It is a misconception that only the discharging physician is responsible for completing the form. The form must be filled out completely, including patient information and follow-up care, by the designated individual, often a nurse or other healthcare professional.
All discharge plans are approved automatically. There is a belief that once the form is submitted, approval is guaranteed. In reality, the Department of Health will review the information and may request additional details or actions before granting approval.
Patients can leave the hospital without a follow-up appointment. Some think that follow-up appointments are not necessary. However, the form requires that a follow-up appointment be scheduled to ensure continuity of care for TB treatment.
The form is only for patients being discharged to their homes. Many believe that the discharge form is only relevant for patients returning home. In fact, it is also necessary for those being discharged to shelters, nursing facilities, or other locations.
Laboratory results are not required for discharge. It is a common misunderstanding that laboratory results do not need to be included. The form requires the most recent acid fast bacilli (AFB) smear results to assess the patient’s infectious status before discharge.
Once the form is submitted, there is no further action required. Some individuals think that submitting the form is the end of the process. However, it is important to follow up and ensure that the Department of Health has received the necessary information and that discharge approval has been granted.

Being aware of these misconceptions can help patients and healthcare providers navigate the discharge process more effectively. Timely and accurate completion of the Hospital Discharge Approval Request Form is essential for the health and safety of patients with tuberculosis.

Key takeaways

Here are some key takeaways for filling out and using the Hospital Discharge Papers form:

Complete the Form in Full: Ensure that every section of the form is filled out completely to avoid delays.
Submit Early: Send the form to the New York City Department of Health & Mental Hygiene at least 72 hours before the planned discharge date.
Contact Information: Include accurate patient contact details, including emergency contact information.
Discharge Location: Clearly state where the patient will be discharged. If it’s a facility other than home, provide the facility's name and contact details.
Follow-Up Appointments: Schedule and document the patient’s follow-up appointment to ensure continuity of care.
Report Laboratory Results: Include the results of the three most recent acid fast bacilli (AFB) smears, noting dates and results.
Detail Treatment Information: Specify the TB medications prescribed, their dosages, and any interruptions in therapy.
Directly Observed Therapy (DOT): Indicate whether the patient has agreed to participate in DOT for their treatment.
Fax the Completed Form: Send the completed form to the Bureau of TB Control at 347-396-7579 for approval.

By following these guidelines, you can help ensure a smooth discharge process for patients with tuberculosis.