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Discharging Patients

Discharging patients requires completion of an electronic prescription (medication “to take out”, or TTO) and electronic discharge summary. Both of these are completed on Lorenzo and guidance can be found under the IT section of the handbook.

‘Short stay’ summaries can be completed for patients who have been in hospital less than 48 hours. This means that only additional medications need to go on the TTO.

In some cases the prescription and discharge letter may have been written much earlier in the admission so please ensure on the day of discharge that the prescription and letter are up to date.

Discharging on warfarin:

If the patient was already on warfarin prior to admission, find out who normally monitors their INR and contact that team to arrange for monitoring to resume on discharge. If it is the RHH anticoagulation service (including their community team) who normally monitors the patient’s INR, complete a request on ICE including recent INR and warfarin dosages. If it is usually managed by the GP:

  1. Fill out “Form B” (found on Intranet → Site index → Anticoagulation and Thrombosis Prevention → Referrals)
  2. Send to GP practice (will likely have to call GP surgery for email address).
  3. Await for response to confirm follow up is arranged.

If the patient has been started on warfarin during this admission, refer them to the anticoagulation service by completing a request on ICE, including recent INR and warfarin dosages.

Discharging on DOAC (Direct Oral AntiCoagulants):

If the patient has been newly started on DOAC for atrial fibrillation or flutter, inform the GP on the discharge letter but there is no need to inform the anticoagulation service.

If the patient has been newly started on DOAC for VTE (PE/DVT) or if the patient has had a recent VTE for which follow-up may be on-going, refer the patient to the anticoagulation service by completing a request on ICE and inform the GP of the plan.

If the patient was already taking a DOAC prior to admission and there has been no change in dose, no action is needed.

Discharging on low molecular weight heparin (LMWH):

Some patients may be discharged on LMWH, particularly if they have a VTE in the context of malignancy or an indwelling line. In these cases it may be more appropriate to discuss with the anticoagulation nurses or haematology in the days prior to discharge to ensure close coagulation monitoring is not needed.