Hospital Discharge Papers – Fill Out and Use This PDF

The Hospital Discharge Papers form, specifically designed by the New York City Department of Health and Mental Hygiene's Bureau of Tuberculosis Control, is a critical document for the safe discharge of patients with infectious tuberculosis (TB). This form ensures that all necessary information, including patient contact details, discharge plans, treatment information, and follow-up appointments, is thoroughly communicated between healthcare providers and the Health Department. To ensure the well-being of the community and the patient, healthcare providers must complete and submit this form with precision and care. For more detailed instructions on filling out the form correctly, click the button below.

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Hospital Discharge Papers PDF Details

The Hospital Discharge Papers form, a comprehensive document mandated by the New York City Department of Health & Mental Hygiene, underlines the meticulous measures necessary for the discharge of patients, particularly those with infectious tuberculosis (TB). Designed to ensure public health safety and patient welfare, this form is a critical tool that health care providers must use to seek approval before discharging TB patients. The approval process, requiring submission at least 72 hours prior to the anticipated discharge date, involves a detailed review by the Department of Health, signifying the thoroughness expected in managing infectious TB cases. This document encompasses multiple sections that cover a wide range of necessary information, including patient contact details, discharge information specifying the facility and destination post-discharge, follow-up appointment details to ensure continuity of care, laboratory results that provide insights into the patient's TB status, and detailed treatment information which specifies medication regimens and any interruptions in therapy. Additionally, the form includes critical instructions for health care providers on how to complete and submit the form correctly, thus serving as a guideline for executing a responsible and safe discharge planning process for TB patients. This process not only emphasizes the significance of regulated patient discharge in preventing TB transmission but also showcases the collaborative effort between health facilities and public health authorities to uphold high standards of public health.

Question	Answer
Form Name	Hospital Discharge Papers
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	tb 354, best way to do hospital discharge planning, atlanta georgia hospital discharge papers, new york hospital discharge papers

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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)

Guidelines for How to Complete and Submit the Mandatory TB

Hospital Discharge Approval Request Form (TB 354)

As of June 16, 2010, Article 11 of the New York City Health Code mandates health care providers to obtain approval from the New York City Department of Health & Mental Hygiene (DOHMH) before discharging infectious TB patients from the hospital.

Discharge of an Infectious (sputum smear positive) Tuberculosis Patient

Health care providers must submit a Hospital Discharge Approval Request Form (TB 354) at least 72 hours prior to the anticipated discharge date. The DOHMH will review the form and approve or request additional information before the patient can be discharged from the health care facility.

Weekday (non-holiday) Discharge: The written discharge plan should be submitted by fax to the Bureau of TB Control between 8am-5pm. Bureau of TB Control staff will review the discharge plan and, within 24 hours, notify the provider of approval or inform the provider of any additional information/actions required for approval prior to discharge.

Weekend and Holiday Discharge: All arrangements for discharge should be made in advance when weekend or holiday discharge is anticipated.

For detailed information about hospital admission and discharge of TB patients, please refer to the New York City Department of Health and Mental Hygiene, Bureau of TB Control Policies and Protocols manual available online at http://www.nyc.gov/html/doh/downloads/pdf/tb/tb-protocol.pdf.

Instructions for Completing the Hospital Discharge Approval Request Form (TB 354)

Section A Patient contact information: Provide the patient’s contact information including patient’s name, a verified address and telephone numbers. In addition, include a name of an emergency contact, the contact’s relationship to the patient and the contact’s verified phone number.

Section B Discharge information: Provide the name and phone number of the discharging facility, the medical record number of the patient at the facility, date the patient was admitted, planned discharge date, and the location to which the patient is being discharged. If the patient will be discharged to a location other than the patient’s address listed in Section A, a facility name (if applicable), address and phone number must be provided. If the patient plans to travel, provide the date and destination.

Section C Patient follow-up appointment: Provide the patient’s follow-up appointment date, as well as the name and contact information of the provider who is assuming patient care. Check all potential obstacles that may affect TB therapy adherence.

Section D Laboratory results: Report the results of the three most recent acid fast bacilli (AFB) smears including the date of specimen collection, specimen source, and AFB smear results and/or grade.

Section E Treatment information: Fill in the date TB treatment was initiated. If there were any treatment interruptions, indicate the reason and number of days treatment was stopped. Check the box next to each prescribed drug and state dosages for each drug. Write in drugs and dosages for drugs not specified. Specify the treatment frequency by checking one of the three boxes, or writing in a different treatment schedule. State whether the patient will have a central line inserted at the time of discharge. If TB medication will be supplied to the patient at discharge, write the number of days for which the medication will be supplied. State whether the patient agreed to be on directly observed therapy (DOT).

After Section E, the name of the person completing the form should be printed and the authorized physician at the discharging facility must print and sign their name, and provide their medical license number and telephone number.

Forms should be faxed to the DOHMH at 347-396-7579.

If you have questions about completing the form, please call 311 and ask to speak to a Bureau of Tuberculosis Control physician.

To fulfill State requirements for communicable disease reporting, health care providers must report all suspected or confirmed TB cases to the Health Department via Reporting Central (formerly Universal Reporting Form (URF)). Instructions for reporting a case of tuberculosis can be found at http://www.nyc.gov/html/doh/html/hcp/hcp-urf.shtml

NOTE: A discharge approval request form does not substitute required case reports.

TB 354 (11/10)

How to Edit Hospital Discharge Papers Online for Free

We have applied the hard work of the best developers to create the PDF editor you are going to apply. The app will assist you to fill out the tb 354 document with no trouble and don’t waste valuable time. Everything you need to do is try out the next quick rules.

Step 1: Click the orange button "Get Form Here" on the following web page.

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atlanta georgia hospital discharge papers empty spaces to fill out

In the Address City State Zip Potential, cid Medical condition specify cid, SECTION D Laboratory Results, Dates of three most recent acid, SECTION E Treatment Information, Specimen source, Acid fast bacilli AFB smear results, cid Positive Grade cid Negative, cid Positive Grade cid Negative, cid Positive Grade cid Negative, Date TB therapy initiated, mm dd yyyy, of the interruption TB medications, cid Injectables specify cid Other, and Frequency cid Daily cid x weekly field, type in your information.

part 2 to entering details in atlanta georgia hospital discharge papers

Identify the important data in the COMPLETED BY THE HEALTH DEPARTMENT, BTBC NUMBER, Discharge approved cid Yes cid No, Reviewed by, NAME OF HEALTH OFFICERDESIGNEE, Date, and mm dd yyyy box.

atlanta georgia hospital discharge papers COMPLETED BY THE HEALTH DEPARTMENT, BTBC NUMBER, Discharge approved cid Yes cid No, Reviewed by, NAME OF HEALTH OFFICERDESIGNEE, Date, and mm dd yyyy blanks to fill out

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