The Hospital Discharge Papers form is a crucial document used by healthcare providers in New York City to obtain approval for discharging patients with infectious tuberculosis (TB) from hospitals. This form ensures that the necessary information is collected and reviewed by the Department of Health before a patient can leave the facility. If you need to fill out this form, click the button below to get started.
The Hospital Discharge Papers form, specifically the TB 354, is a crucial document designed for managing the safe discharge of patients with infectious tuberculosis (TB) from healthcare facilities. This form is mandated by the New York City Department of Health and Mental Hygiene and must be completed in full to ensure compliance with health regulations. It includes several sections that capture essential patient information, discharge details, and follow-up care plans. Section A requests the patient's contact information and an emergency contact, while Section B focuses on discharge specifics, including the facility's details and the patient's intended discharge destination. In Section C, healthcare providers outline follow-up appointments and identify potential barriers to adherence to TB therapy. Laboratory results related to acid fast bacilli (AFB) smears are documented in Section D, and Section E covers treatment information, including medications and any interruptions in therapy. Completing this form accurately is vital for ensuring that patients receive appropriate care and support as they transition out of the hospital setting.
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)
Completing the Hospital Discharge Papers form is an essential step in ensuring that a patient can safely transition from a healthcare facility. After filling out this form, it will need to be submitted to the appropriate department for approval before the discharge can take place. Below are the steps to fill out the form correctly.
The Hospital Discharge Approval Request Form is required for patients diagnosed with infectious tuberculosis (TB) before they can be discharged from a healthcare facility. This form ensures that the New York City Department of Health & Mental Hygiene reviews the patient’s discharge plan and confirms that all necessary precautions are taken to prevent the spread of TB.
Healthcare providers must submit the form at least 72 hours before the anticipated discharge date for infectious TB patients. This timeframe allows the Department of Health to review the information and respond appropriately.
The form requires several sections to be filled out completely:
If the form is not submitted at least 72 hours in advance, the discharge of the patient may be delayed. The Department of Health needs sufficient time to review the discharge plan and ensure that all necessary actions are taken to protect public health.
If you have questions about completing the Hospital Discharge Approval Request Form, you can call 311 and ask to speak to a physician from the Bureau of Tuberculosis Control. They can provide guidance and clarify any uncertainties you may have.
No, the discharge approval request form does not replace the requirement for case reporting. Healthcare providers must also report all suspected or confirmed TB cases to the Health Department via Reporting Central. Detailed instructions for reporting can be found on the Department of Health's website.
Completing the Hospital Discharge Papers form can be a straightforward process, but several common mistakes can hinder its effectiveness. One frequent error is failing to provide complete patient contact information. All fields, including the patient's name, date of birth, and verified contact numbers, must be filled out accurately. Incomplete information can lead to delays in processing and potential issues with follow-up care.
Another common mistake involves neglecting to specify the discharge destination. If the patient is not returning home, it is essential to indicate the name and address of the facility to which they are being discharged. Omitting this information can create confusion regarding the patient's care post-discharge and may complicate the approval process.
Individuals often overlook the importance of documenting the patient’s follow-up appointment. This section should clearly state the date of the appointment and the physician assuming care. Failure to provide this information can hinder continuity of care and may negatively impact the patient's health outcomes.
Additionally, many people forget to check all potential barriers to tuberculosis therapy adherence. This section is crucial for identifying challenges that the patient may face after discharge. By not marking any barriers, the health department may not be fully aware of the patient's situation, which could affect treatment effectiveness.
Inaccuracies in laboratory results are another common issue. It is vital to report the dates and results of the three most recent acid fast bacilli (AFB) smears accurately. Errors in this section can mislead health care providers about the patient's current health status and treatment needs.
Some individuals fail to indicate whether there was an interruption in therapy. If there were any interruptions, it is necessary to provide reasons and duration. Omitting this information may lead to misunderstandings regarding the patient's treatment history and compliance.
Another mistake involves neglecting to specify the dosage of prescribed TB medications. Each medication should be clearly listed with the appropriate dosage, as inaccuracies can lead to improper treatment and potentially serious health consequences.
People sometimes forget to indicate whether a central line was inserted. This detail is important for understanding the patient's treatment needs and ensuring appropriate care is provided after discharge.
Moreover, the section regarding the number of days of medication supplied at discharge is often left blank. This information is critical for ensuring that the patient has enough medication to continue their treatment without interruption.
Finally, individuals may neglect to ensure that the responsible physician at the discharging facility signs the form. This signature is necessary for validating the discharge and ensuring that all required protocols have been followed. Without it, the form may be rejected, causing further delays in the discharge process.
When a patient is discharged from a hospital, several important documents may accompany the Hospital Discharge Papers. Each of these documents serves a unique purpose in ensuring a smooth transition from hospital care to home or another facility. Here’s a list of common forms you might encounter alongside the discharge papers.
Each of these documents plays a vital role in the patient’s care transition. They ensure that the patient and their caregivers have the necessary information to continue treatment effectively and safely. Understanding these forms can help patients feel more confident and prepared as they leave the hospital.
The Hospital Discharge Papers form serves a critical role in the healthcare system, particularly for patients being discharged from hospitals. Several other documents share similarities with this form, focusing on patient information, care continuity, and compliance with health regulations. Below is a list of these similar documents:
When filling out the Hospital Discharge Papers form, it is essential to follow certain guidelines to ensure accuracy and compliance. Below is a list of things you should and shouldn't do during this process.
In reality, the Hospital Discharge Approval Request Form is mandatory for patients with infectious tuberculosis. Health care providers must submit this form to comply with New York City Health Code regulations.
This is not true. The form must be submitted at least 72 hours prior to the planned discharge date to allow for proper review and approval by the Department of Health.
While the physician at the discharging facility must sign the form, it can be completed by any authorized individual involved in the patient's care.
This is misleading. The approval process can take up to 24 hours on weekdays, and arrangements should be made in advance for weekend or holiday discharges.
Each patient’s discharge papers are unique and must reflect their specific medical history, treatment details, and follow-up care requirements.
This is incorrect. Patients must wait for approval from the Department of Health before they can be discharged from the facility.
In fact, follow-up appointments are critical for ensuring continued care and treatment adherence. The form requires details about these appointments.
This is false. The form must include comprehensive information about all medications prescribed, including dosages and treatment frequency.
Filling out and using the Hospital Discharge Papers form is crucial for ensuring proper care for patients with tuberculosis (TB). Here are five key takeaways to keep in mind: