Why Discharge Planning Is Examined
Discharge planning is a core clinical and communication competency examined in OSCE stations involving: prescribing TTOs, communication with patients and families about going home, structuring a discharge summary, and clinical reasoning (is this patient safe to go home?). Poor discharge is a leading cause of readmission and harm in NHS settings.
💡 Tip
Discharge planning starts on admission. Asking "what do you need to be able to go home safely?" on day 1 prevents avoidable delays and ensures the right support is arranged in time.
The Safe Discharge Checklist — MEDS HOME
🧠 Mnemonic
MEDS HOME — safe discharge framework:
- M edical fitness — is the acute problem resolved or stable?
- E ducation — does the patient understand their diagnosis, medications, and follow-up?
- D rugs — are TTOs written, explained, and dispensed?
- S afety-netting — does the patient know what to do if they deteriorate?
- H ome circumstances — is the home environment suitable?
- O ccupational therapy / social care — are required packages in place?
- M obility — can they mobilise safely (physiotherapy assessment)?
- E scalation pathway — does the GP have the discharge summary and know what to monitor?
Is the Patient Medically Fit for Discharge?
Before agreeing to discharge, confirm:
| Criterion | Specific check |
|---|---|
| Acute problem resolved/stable | Infection treated, procedure completed, vitals stable |
| Observations within normal range | Afebrile, HR/BP/SpO2 acceptable |
| Eating, drinking, mobilising | Nutrition maintained, tolerating oral medication |
| No planned procedures outstanding | No pending investigations that require inpatient setting |
| Anticoagulation/medications safe to go home on | INR therapeutic if on warfarin; stable on new medication |
To Take Out (TTO) Prescriptions
TTOs are the discharge medications written for the patient to take home. In many OSCE stations you will be asked to write or review a TTO.
TTO prescription checklist:
- 1Review the inpatient drug chart — which medicines should continue?
- 2Stop medicines no longer needed — course completed, indication resolved
- 3Add new medicines started during admission
- 4Consider interactions and monitoring requirements
- 5Ensure adequate supply — standard NHS practice is 14-28 days' supply; chronic conditions may receive 3 months
⚠️ Red Flag
Common TTO prescribing errors examined in OSCEs:
- Omitting steroid taper instructions (always specify dose and duration for prednisolone courses)
- Forgetting anticoagulant duration (e.g., 3 months of LMWH or DOAC for PE)
- Not reconciling pre-admission medications (especially antihypertensives stopped during acute illness)
- Missing allergy documentation
- Not prescribing prophylactic LMWH post-surgery if outpatient
Discharge Summary — Key Components
A good discharge summary must include:
| Section | Content |
|---|---|
| Patient details | Name, DOB, NHS number, address |
| Admission details | Date admitted, ward, admitting team |
| Reason for admission | Presenting complaint |
| Significant findings | Examination, investigations, results |
| Diagnoses | Primary + secondary |
| Procedures performed | Operations, biopsies, endoscopies |
| Treatment given | Medications, procedures, therapies |
| Discharge medications | Full list with doses — including changes from pre-admission |
| Follow-up | Outpatient appointments, tests pending |
| Safety-netting | What the patient has been told to watch for |
| GP actions required | Repeat bloods, medication reviews, referrals |
Home Circumstances Assessment
Before discharge, ask the patient:
- "Who do you live with?"
- "Do you have any steps or stairs to manage?"
- "Before admission, how were you managing at home — shopping, cooking, washing?"
- "Do you receive any care at home currently?"
- "Is there anything at home that would make you worried about going back?"
Refer to:
- Occupational therapist (OT) — home assessment, equipment (rails, raised toilet seat, shower chair), care package
- Physiotherapist — mobility, walking aid, stair assessment
- Social worker — care package coordination, safeguarding, residential or nursing home placement
- District nurse — wound care, medication administration, monitoring at home
- Community pharmacist — medication compliance, dosette boxes, blister packs
Discharge Communication — Patient and Family
Key points to cover when explaining discharge:
- 1Diagnosis and what was found/done
- 2Medications — what is new, what has changed, and why; how to take them
- 3Activity and lifestyle advice — driving restrictions, wound care, dietary modification
- 4Follow-up — outpatient appointment date, which team, what for
- 5Safety-netting — specific red flag symptoms to return for
- 6Who to contact — GP, outpatient nurse, A&E if urgent
💎 Clinical Pearl
Check understanding — don't just hand over a leaflet. Ask: "Just to make sure I've explained everything clearly, could you tell me in your own words what you're going to do when you get home?" This is often assessed explicitly in communication OSCEs.
Patients Unsuitable for Discharge — Red Flags
Do not discharge if:
- Vital signs not stable for 12-24 hours or more
- Patient still requires IV medication that cannot be converted to oral
- Planned surgery or investigation outstanding
- Social circumstances inadequate and no arrangement in place
- Patient lacks capacity to consent to discharge without proper safeguards
- Safeguarding concern not resolved
Frequently Asked Questions
"What is the difference between a discharge summary and a TTO prescription?"
A discharge summary is a clinical document sent to the GP summarising the admission, findings, diagnoses, treatment, and follow-up plan. A TTO (To Take Out) prescription is a legal prescription document for the medications the patient takes home. Both are produced at discharge. The discharge summary may reference medication changes but the TTO is the formal prescribing document.
"What should you do if a patient wants to self-discharge against medical advice?"
Assess capacity — does the patient understand, retain, weigh up, and communicate their decision? If they have capacity, they have the legal right to leave. Document that you have explained the risks and they have made an informed decision. Provide them with safety-netting information and ensure the GP is notified. If capacity is questionable, involve a senior and consider a Mental Capacity Act assessment. Never physically detain a patient with capacity.
"How long should a TTO prescription last?"
For hospital-initiated treatments (antibiotics, steroids): prescribe the complete course. For ongoing chronic medications: 14-28 days in most trusts, after which the patient's GP takes over prescribing. For some controlled drugs or expensive medications: discuss with the relevant team. Always check local prescribing policy.
"What is medication reconciliation and why does it matter at discharge?"
Medication reconciliation is the process of comparing the patient's pre-admission medication list with the inpatient chart and identifying discrepancies — intentional or unintentional. At discharge, this ensures that medications stopped during the admission for good reason (e.g., ACE inhibitor during AKI) are either restarted or the GP is clearly instructed not to restart them. Studies show that medication errors at care transitions are a leading cause of preventable readmission.
"How do you arrange a package of care for a patient going home?"
Refer to the ward social worker as early as possible (day 1 ideally). A social care needs assessment is arranged. Based on the OT and physiotherapy assessment, a care package is agreed — typically 2-4 daily calls from carers to assist with personal care, meals, and medication. Local authority funded if eligible. For more complex needs, a step-down intermediate care bed or residential placement may be arranged. This process takes days, so early referral prevents unnecessary length of stay.
Related Posts
- Frailty Assessment OSCE — identifying patients who need complex discharge planning
- Medication Review OSCE — medication reconciliation at the point of discharge
- Nutrition Screening OSCE — ensuring nutritional support is in place post-discharge