The Hospital Discharge Papers form, formally designated by the New York City Department of Health and Mental Hygiene as a critical document, is essential for the discharge process of patients diagnosed with infectious Tuberculosis (TB). Its comprehensive nature requires detailed information on the patient's contact details, discharge data, follow-up appointments, laboratory results, and specific treatment plans to ensure a coordinated and safe transition from hospital care. Ensuring this form is filled out accurately is paramount; click the button below for a guided process in completing the form.
When patients diagnosed with infectious tuberculosis (TB) are ready to leave the hospital, a critical and mandatory step ensures their continued recovery and the public's safety—the Hospital Discharge Approval Request Form (TB 354). Instituted by the New York City Department of Health & Mental Hygiene, this form mandates health care providers to seek approval before discharging infectious TB patients, reflecting the city's commitment to controlling the spread of this serious disease. The form encompasses several crucial sections, including patient contact information, discharge and follow-up details, laboratory results, and treatment information, all aimed at providing a comprehensive post-discharge plan. It requires health care providers to supply detailed patient information, including planned discharge location, any potential barriers to TB therapy adherence, and results of recent TB tests, ensuring that patients receive consistent and effective treatment after leaving the hospital. With a direct impact on patient care and public health, the form and its stipulated process highlight the collaborative efforts between health care providers and the health department, ensuring adherence to treatment and monitoring of TB patients after discharge.
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: _______/_______/_______
mm
dd
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. #: (
Fl.:
Patient medical record #:
Date of admission:
/
Planned discharged date:
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:
Apt./Fl.:
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:
Physician assuming care:
Cell. #: (
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
SECTION E: Treatment Information
Date TB therapy initiated:
Interruption in therapy?
☐ Yes
☐ No
If yes, state the reason and duration
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
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
Print name of individual filling out this form:
Date:
Name of responsible physician at the discharging facility:
License #:
Signature of responsible physician at the discharging facility:
COMPLETED BY THE HEALTH DEPARTMENT
BTBC NUMBER:
Discharge approved: ☐ Yes
Action required before discharge:
Reviewed by:
NAME OF HEALTH OFFICER/DESIGNEE
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.
Filling out the Hospital Discharge Approval Request Form is a critical step towards ensuring a successful transition for patients diagnosed with tuberculosis as they move from hospital care back into their community. This procedure involves a thorough compilation of information ranging from personal contact details and medical history to laboratory results and treatment plans. It's designed to safeguard public health by coordinating care and ensuring that the Department of Health and Mental Hygiene (DOHMH) approves of the discharge plan for infectious TB patients. Once completed and submitted, the DOHMH reviews the form, a process that's especially crucial for managing tuberculosis patients effectively outside the hospital setting.
After completing all sections, fax the form to the DOHMH at 347-396-7579. For any queries or need for clarifications, contact 311 and ask to connect with a Bureau of Tuberculosis Control physician. Remember, this form is an addendum to, not a substitute for, mandatory communicable disease reporting required by the State. It's an instrumental part of ensuring public safety and the continuance of care for tuberculosis patients.
The Hospital Discharge Approval Request Form (TB 354) is required by the New York City Department of Health & Mental Hygiene (DOHMH) for the discharge of patients with infectious tuberculosis (TB) from hospitals. It helps ensure that patients receive continuous and appropriate care after discharge, minimizing public health risks associated with TB.
Health care providers must submit the form at least 72 hours before the anticipated discharge date of an infectious TB patient. This allows the DOHMH adequate time to review and either approve the discharge or request additional information as needed.
The form should be completed in detail and faxed to the Bureau of TB Control at 347-396-7579. It's important to provide all requested information, including the patient's medical and contact details, discharge information, follow-up care, and treatment information.
The form is divided into several sections, each requiring specific information:
After submission, the Bureau of TB Control staff will review the discharge plan. Within 24 hours on weekdays (excluding holidays), the health care provider will be notified of the approval or if additional information is required.
Yes. While the procedure remains the same, all arrangements for discharging patients on weekends or holidays should be made in advance. This ensures that the patient's discharge does not get delayed due to the timing.
If changes to the initial discharge plan are necessary, health care providers should immediately contact the Bureau of TB Control to provide updates or request guidance. Timely communication is key to ensuring the patient's and public's health.
For detailed guidelines on completing the form or for additional assistance, health care providers can refer to the Bureau of TB Control Policies and Protocols manual online or call 311 to speak to a Bureau of Tuberculosis Control physician.
Filling out hospital discharge papers is an important step in ensuring that a patient receives the appropriate follow-up care after leaving the hospital. However, mistakes in completing these forms can lead to delays or complications in the patient's care. Here are six common mistakes people make when filling out hospital discharge papers:
Not providing complete patient contact information: It's crucial to fill out all sections related to the patient's contact information, including multiple phone numbers and a verified address. Missing details can make it difficult to follow up with the patient after discharge.
Incorrect or incomplete discharge information: The section on discharge information must accurately describe the discharging facility, the medical record number, admission and discharge dates, and the location to which the patient is being discharged. This information is vital for coordinating post-discharge care.
Omitting follow-up appointment details: A common oversight is not providing the date and contact information of the provider who will assume care of the patient. This information is essential to ensure the patient receives continuous care and treatment.
Leaving out laboratory results: The form requires details of the three most recent acid fast bacilli (AFB) smears, including dates and results. Skipping this information can hinder the health department's ability to monitor the patient's condition effectively.
Failing to specify treatment information correctly: The date treatment was initiated, interruptions in treatment if any, medications and dosages, and the treatment frequency must be accurately recorded. This information helps in understanding the patient's treatment plan and ensuring continuity of care.
Not confirming the patient’s agreement to directly observed therapy (DOT): It's important to check whether the patient agreed to be on DOT and provide medication details for discharge. This ensures that there is a plan in place for the patient's treatment adherence.
By avoiding these mistakes, the process of discharging a patient with tuberculosis can be smoother, ensuring they receive the necessary post-discharge care without unnecessary delays.
When managing the discharge of patients, especially those with infectious diseases like tuberculosis, healthcare professionals rely on a comprehensive set of documents to ensure continuity of care and compliance with health regulations. Alongside the Hospital Discharge Approval Request Form, several other documents play a crucial role in this process.
Together, these forms and documents provide a structured pathway for patients transitioning from hospital to home care or another healthcare facility, ensuring they receive the necessary support and instructions for a safe and effective recovery. It's a coordinated approach that prioritizes patient health and continuity of care beyond the hospital setting.
Medical Release Forms: Like Hospital Discharge Papers, these documents contain important health-related information and instructions for care after a patient leaves a medical facility. They ensure a continued care plan is followed and outline any medications or necessary follow-up appointments, similar to the treatment and follow-up sections of the discharge papers.
Prescription Information Sheets: These documents provide detailed information about medications prescribed to a patient, including dosage, frequency, and potential side effects. This is closely related to the section of discharge papers that lists TB medications and dosages provided at discharge, ensuring the patient and their caregivers understand how to manage the medication regimen.
Patient Information Sheets: Given at the beginning of a hospital stay, these sheets collect contact and personal health information. They are similar to the Patient Contact Information section of the discharge papers, ensuring the hospital has all necessary details to provide personalized and effective care.
Advance Directive Forms: Advance Directives provide instructions about a patient's preferences for treatment and care in situations where they might not be able to express their wishes. While serving a different purpose, they similarly require detailed personal and health information from the patient, a key aspect of discharge documents.
Emergency Contact Forms: Similar to the emergency contact details provided in the Hospital Discharge Papers, these forms collect information about who to contact in case of an emergency, ensuring that family members or designated individuals can be informed and involved in the patient's care if necessary.
Lab Results Reports: These reports detail the findings of laboratory tests, much like the Laboratory Results section of the discharge papers. They are vital for the ongoing care of patients, especially for those with conditions requiring monitoring, such as TB, by providing clear records of test outcomes and diagnoses.
Follow-Up Appointment Cards: These cards provide specific details about who the patient should see, and when, for their next appointment, paralleling the Patient Follow-Up Appointment section of the discharge papers. Both ensure the patient is aware of and attends necessary post-discharge medical consultations.
When completing the Hospital Discharge Papers form, there are several do's and don'ts to keep in mind to ensure the process is carried out smoothly and accurately.
Things You Should Do:
Things You Shouldn't Do:
Many people have misconceptions about Hospital Discharge Papers, particularly the Hospital Discharge Approval Request Form issued by the New York City Department of Health and Mental Hygiene Bureau of Tuberculosis Control. Here are nine common misunderstandings clarified:
It is only for tuberculosis patients: While it focuses on TB patients, the form is a standard procedure for the discharge of any patient with an infectious disease that poses a public health concern, ensuring continued treatment and monitoring.
A signature from the patient is required: The form requires the signature of the responsible physician at the discharging facility, not the patient. This highlights the responsibility of the medical professional in ensuring proper discharge protocol.
It can be submitted at any time: The form must be submitted at least 72 hours prior to the anticipated discharge date to allow sufficient time for the Department of Health and Mental Hygiene to review.
Patient follow-up is optional: Section C mandates that details about the patient's follow-up appointment be included, underscoring the importance of continued care after discharge.
Personal contact information is not necessary: Patient contact information is crucial, as outlined in Section A, ensuring that the patient can be reached for follow-up appointments or in case of an emergency.
The form is a substitute for case reports: Submitting a discharge approval request form does not replace the legal requirement to report confirmed or suspected TB cases through the appropriate channels, as stated at the end of the document.
Approval is guaranteed upon form submission: Receipt of the form by the Department of Health does not equate to automatic approval. It must first be reviewed, and the provider will be notified of the approval or if additional information is needed.
Details about TB therapy are irrelevant: Section E demands detailed information about the TB treatment plan, emphasizing the importance of medication adherence and ongoing management of the disease post-discharge.
It's unnecessary to report potential barriers to therapy adherence: Identifying potential obstacles to TB therapy adherence is essential for creating an effective follow-up plan, ensuring the patient receives the necessary support to complete their treatment.
Understanding these aspects of the Hospital Discharge Approval Request Form helps in recognizing its role in public health. It ensures that patients with infectious diseases like tuberculosis receive the required care and monitoring after leaving the hospital, aiming to prevent the spread of the disease within the community.
Filling out Hospital Discharge Papers, specifically the TB Hospital Discharge Approval Request Form (TB 354) in New York City, requires careful attention to ensure a smooth transition for patients diagnosed with infectious Tuberculosis (TB) from hospital care to their next phase of treatment or living situation. Here are five key takeaways:
Completing the Hospital Discharge Approval Request Form attentively and adhering to the outlined protocol supports effective TB control and management, safeguarding both the patient and the broader community.
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