Editing Management of Care (section)

=== Transfer, discharge, and referral ===
'''Discharge planning begins on admission.''' It is interdisciplinary, and it is based on the patient's expected level of function, support system, home environment, finances, and health literacy. A transfer to another unit or facility requires a report to the receiving nurse, transfer of the record and medication list, and provider orders for the new setting.

'''Referrals''' connect the patient to resources outside the nurse's scope. Common referral targets tested on examinations include physical, occupational, and speech therapy; the registered dietitian for nutrition needs including swallowing-safe diets; the social worker for financial, housing, placement, and psychosocial resources; the case manager for coordination and utilization; respiratory therapy; the wound and ostomy nurse; the chaplain for spiritual needs; home health; and hospice. In most systems the RN may initiate a referral, while an order may be required for the service to be reimbursed.

'''Medication reconciliation''' occurs at admission, at every transfer between levels of care, and at discharge. It compares what the patient was actually taking, including over-the-counter drugs, herbals, and supplements, against what is ordered now.