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Basic Information
Discharge Planning Tools

CREATING the ESSENTIAL TOOLS and MATERIALS

This section discusses resources that could be helpful in supporting families’ discharge preparation.

There are lots of useful tools and resources out there. We share some of our favorites on our website. 

The tools you choose for your NICUs, follow-up clinics, and other care settings should be reviewed regularly to make sure they a useful, relevant, and up-to-date.

You may want to ask your NICU family advisory council members for their help and support when choosing what you'll use. Experienced NICU graduate families and NICU Parent Support organizations can provide a wealth of information.

Remember, while it may be tempting to adopt resources used by other NICUs, your goal should be to find - or create - resources that are uniquely useful for your specific community.

tools

MATERIALS that SUPPORT the DISCHARGE PROCESS

When we have the right tools and resources in place, NICU families benefit. There are helpful resources that discharge teams can use to support families’ discharge preparation.

The discharge summary, NICU hospital course roadmap, and discharge planning folder are essential tools.

 

In this context, the NICU hospital course roadmap is intended to be a strategic plan that defines a goal or desired outcome and includes the major steps or milestones needed to reach it.

DISCHARGE SUMMARY

  • Discharge summaries should at minimum include all the following items:

  • Infant’s name in the hospital (and after discharge, if they are different) 

  • Discharge diagnoses  

  • Condition  at discharge

  • Discharge physical exam findings (highlighting any abnormal physical findings)

  • Discharge medications and instructions for administering them

  • Home feeding plan

  • Newborn hearing screen results and guidance for follow-up screening

  • Results of newborn screenings and when they were done

  • Car seat test results

  • Which immunizations the baby has received and which ones they still need - along with an explanation about the timing and importance of vaccination and a recommended schedule

  • Results of lab tests, including which tests results you may still be waiting for 

  • Prognosis, if guarded

  • Any medical equipment the infant needs (e.g. oxygen, gastrostomy tube, formulas)

  • Pertinent social, family, or medical history (as understood by the baby's caregivers)

  • Description of the resources needed to support the family's communication needs, including medical interpretation services

  • Referrals to programs, resources, and specialists to address specific diagnoses

  • ​Community resources (e.g., counseling services, mental health support, substance dependency treatment, visiting nurses, financial resources, etc.)

  • ​Community service program referrals made or recommended (e.g., community health nursing agencies, early intervention services) and any counseling opportunities available to the family

  • ​Any tasks to be completed (e.g., follow-up appointments or test that were recommended but not yet scheduled)

  • Discharge summary should be formatted from a structured template with section headings

  • Discharge summary would, ideally, be translated into the family’s preferred language

  • As part of the discharge process, provide families with copies of the final discharge summary and directions on how the family can get an official copy of the medical record, if they would like

  • Provide at least two copies of the discharge summary (one for the medical home and one for the child’s family that they can share with home visiting or emergency department services as needed). If the infant is seen by medical specialists, either provide the specialists with copies of the discharge summary directly or provide the family with copies of the discharge summary to give to the specialists

NICU ROADMAP

  • Have a roadmap or equivalent visual schematic that outlines the time span from the birth and NICU admission to NICU discharge. On the roadmap, include following:

  • For the family, individualization of discharge educational goals/tasks and a suggested timeline to complete the items

  • For the infant, medical milestones for the infant to achieve, relevant to the infant’s gestational age and unique developmental progression

  • Identification of short- and long-term follow-up needs of the infant and plans for the transition to pediatric care

DISCHARGE PLANNING FOLDER

  • Provide a discharge planning and education folder, to be used during the discharge planning process to guide the family through the topic areas and tasks they and their baby must achieve for discharge. It may contain a checklist and other educational materials that allow the family and staff to track the family’s progress with discharge preparation.

WRITTEN DISCHARGE INFORMATION

  • All printed materials given to families should be written in a manner that is simple, clear, concise, and devoid of medical jargon. This aids understanding and decreases confusion. Written materials should be reviewed to ensure that they meet health education standards. When possible, include written and illustrated materials in the family’s preferred language to support and reinforce verbal instruction.

SUPPLEMENTAL DISCHARGE EDUCATIONAL MATERIALS

  • Parents should be provided with materials (e.g., binders, folders, videos, websites) to supplement bedside infant care skill knowledge and education.

JOURNAL

  • Some families benefit from having a journal to document their discharge education, describe experiences, and serve as a place to keep track of their observations, questions, and concerns

What knowledge and skills does the family need?

Creating the essential tools and materials

Who are the essential members of the NICU transition team?

Who - When - Where - What - Why - How

It's all about family-centered care!

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