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Homepage ⇉ Free Hospital Discharge Papers PDF Template
Outline

When a patient in New York City is ready to be discharged from the hospital with a diagnosis of tuberculosis (TB), a very specific procedure must be followed according to the New York City Department of Health & Mental Hygiene's regulations. The Hospital Discharge Approval Request Form, also known as TB 354, plays a critical role in this process. This form, detailed and comprehensive, is designed to ensure that patients receive consistent care and monitoring after their hospital stay, particularly to manage infectious diseases like TB effectively. Health care providers are required to submit this form 72 hours before the patient's planned discharge date, providing essential details such as patient contact information, discharge information, follow-up appointments, laboratory results, and treatment information. The form serves as a bridge between hospital care and aftercare, necessitating information on treatment continuation, potential barriers to therapy adherence, and whether the patient has agreed to directly observed therapy (DOT). Approvals from the Department of Health are mandatory for the discharge of infectious TB patients, reflecting the city's commitment to public health and TB control. The intricate process, involving the submission and review of the form, underscores the importance of due diligence and coordination among healthcare providers to prevent the spread of tuberculosis and ensure patient safety and well-being.

Document Preview

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. #: (

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

–

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fl.:

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient medical record #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of admission:

 

 

/

 

/

 

 

 

 

 

 

Planned discharged date:

 

 

/

 

 

 

 

 

 

 

 

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mm

dd

yyyy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mm

 

 

dd

 

yyyy

 

 

 

 

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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tel. #: (

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

–

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt./Fl.:

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

 

 

 

 

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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:

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mm

dd

yyyy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician assuming care:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tel. #: (

 

 

 

 

)

 

 

 

 

 

–

 

 

 

 

 

Cell. #: (

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

_______/_______/_______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Positive Grade: ______

 

☐ Negative

 

 

 

 

 

 

 

_______/_______/_______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Positive Grade: ______

 

☐ Negative

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION E: Treatment Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date TB therapy initiated:

 

/

 

 

/

 

 

 

 

 

 

Interruption in therapy?

 

☐ Yes

 

☐ No

 

 

If yes, state the reason and duration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mm

dd

 

 

yyyy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

☐ Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

☐ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Print name of individual filling out this form:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

/

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mm

dd

 

yyyy

 

 

 

 

Name of responsible physician at the discharging facility:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of responsible physician at the discharging facility:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tel. #: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETED BY THE HEALTH DEPARTMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BTBC NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Discharge approved: ☐ Yes

☐ No

Action required before discharge:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reviewed by:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF HEALTH OFFICER/DESIGNEE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mm

 

 

 

 

 

 

 

 

 

 

dd

 

yyyy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

TB 354 (11/10)

Get PDF Form

Document Attributes

Fact Name Fact Detail
Governing Law Article 11 of the New York City Health Code
Department Oversight New York City Department of Health & Mental Hygiene (DOHMH)
Purpose of the Form To obtain approval from DOHMH before discharging infectious TB patients from the hospital
Submission Timing At least 72 hours prior to the anticipated discharge date
Weekday Discharge Process Submit discharge plan between 8am-5pm for review within 24 hours
Weekend and Holiday Discharge Arrangements must be made in advance
Key Sections of the Form Includes patient contact information, discharge information, follow-up appointments, laboratory results, and treatment information
Contact for Assistance Call 311 and ask to speak to a Bureau of Tuberculosis Control physician

How to Fill Out Hospital Discharge Papers

Filling out the Hospital Discharge Approval Request Form is a crucial step in ensuring a smooth transition for patients diagnosed with tuberculosis from hospital care to their next phase of treatment or housing. This form helps the New York City Department of Health and Mental Hygiene track and approve the discharge of infectious TB patients to prevent the spread of the disease. It is imperative that this form be submitted at least 72 hours before the anticipated discharge to allow adequate time for review. Here are detailed instructions to help you complete the form correctly.

  1. Start with Section A: Patient Contact Information.
    • Fill in the patient's full name, date of birth (DOB), and telephone numbers. Ensure these details are accurate for future contact.
    • Enter the patient's home address, including apartment number, city, state, and ZIP code.
    • Provide the name, relationship, and telephone number of an emergency contact person.
  2. Continue with Section B: Discharge Information.
    • Write the name and telephone number of the discharging facility.
    • Include the patient's medical record number, date of admission, and the planned discharge date using the format MM/DD/YYYY.
    • Select the appropriate option where the patient will be discharged to and fill in additional details if the patient will not be returning home.
    • If the patient is scheduled to travel outside of NYC, specify the date and destination.
  3. Proceed to Section C: Patient Follow-Up Appointment.
    • Indicate the date of the patient’s follow-up appointment and provide the name and contact information of the physician assuming care after discharge.
    • Check any potential barriers to TB therapy adherence that apply to the patient.
  4. Move on to Section D: Laboratory Results.
    • List the dates and results of the three most recent acid fast bacilli (AFB) smears, including specimen source and whether the result was positive or negative.
  5. Fill in Section E: Treatment Information.
    • Note the date TB therapy was initiated and detail any interruptions in therapy, including the reason and duration.
    • Record the TB medications prescribed at discharge, the dosage for each, and the treatment frequency.
    • Indicate if a central line was inserted and how many days of medication are supplied to the patient at discharge.
    • Confirm if the patient agreed to be on directly observed therapy (DOT).
  6. Complete the form by printing the name of the individual filling out this form and the responsible physician at the discharging facility. The physician must also sign, provide their license number and telephone number.
  7. Fax the completed form to the DOHMH at 347-396-7579. If you have any questions or need further assistance, contact the Bureau of Tuberculosis Control by calling 311.

By meticulously following these steps, health care providers will ensure that all necessary information is communicated effectively to the New York City Department of Health and Mental Hygiene. This process not only complies with the legal requirements but also contributes to the careful monitoring and control of tuberculosis, safeguarding the health of the community.

More About Hospital Discharge Papers

  1. What is the purpose of the Hospital Discharge Approval Request Form (TB 354)?

    The Hospital Discharge Approval Request Form (TB 354) is a mandatory submission for healthcare providers to the New York City Department of Health & Mental Hygiene (DOHMH) for obtaining approval before discharging any patient diagnosed with infectious Tuberculosis (TB) from the hospital. This is in compliance with Article 11 of the New York City Health Code, ensuring a controlled and safe discharge process for TB patients.

  2. How and when should the Hospital Discharge Approval Request Form be submitted?

    Healthcare providers must submit the Hospital Discharge Approval Request Form at least 72 hours prior to the patient's planned discharge date to allow the DOHMH time to review and approve the discharge plan. Forms should be faxed to 347-396-7579 between 8 am and 5 pm on weekdays (non-holiday) for a review within 24 hours. For weekend or holiday discharges, arrangements should be made in advance, following the same submission process.

  3. What information is required on the Hospital Discharge Approval Request Form?

    • Patient contact information including name, address, telephone numbers, and emergency contact details.
    • Details of the discharging facility, patient's medical record number, admission and planned discharge dates, and discharge destination.
    • Patient's follow-up appointment date, physician assuming care, and potential barriers to TB therapy adherence.
    • Three most recent acid fast bacilli (AFB) smear results including dates, specimen source, and results/grade.
    • TB treatment information including initiation date, treatment interruptions, drugs and dosages, treatment frequency, central line information, and whether the patient agreed to directly observed therapy (DOT).

    After completing the specified sections, the form must be finalized with the print name and signature of the responsible physician at the discharging facility, along with their medical license number and contact information.

  4. If additional information or actions are required for discharge approval, how will the healthcare provider be notified?

    Once the Bureau of TB Control reviews the discharge plan, they will notify the provider within 24 hours if the discharge is approved. If the plan requires any additional information or actions before approval, the provider will be informed accordingly. It's vital that providers submit the form in the given timeframe to facilitate this review process and ensure necessary adjustments can be made promptly.

  5. Does completing the Hospital Discharge Approval Request Form suffice for TB case reporting?

    No, completing and submitting the Hospital Discharge Approval Request Form is just one step in managing TB patients' discharge process. In addition to this form, healthcare providers are also required to report all suspected or confirmed TB cases to the Health Department through Reporting Central, as per State communicable disease reporting requirements. This ensures all cases of TB are appropriately recorded and managed in the broader public health context.

Common mistakes

Completing the Hospital Discharge Approval Request Form requires attention to detail. Often, people make mistakes that can delay the discharge process. Listed below are eight common errors:

  1. Not providing complete Patient Contact Information including a verified address and telephone numbers. It’s imperative for ensuring that the patient can be contacted for follow-up care.

  2. Leaving out the Emergency Contact details. This information is crucial in case of an emergency or the need for additional support for the patient.

  3. Failing to specify the correct Discharge Information, such as the name of the discharging facility or the medical record number. This creates confusion and potential delays.

  4. Omitting the planned Discharge Destination if it's different from the patient's address listed, including incomplete addresses for facilities or incorrect telephone numbers.

  5. Not accurately detailing the Follow-Up Appointment information, including the date and contact information of the provider assuming care.

  6. Skipping sections on Potential Barriers to TB Therapy Adherence. Recognizing these barriers early can lead to a more successful treatment plan.

  7. Incomplete Laboratory Results and Treatment Information, including the dates of specimen collection and results of AFB smears, or incorrect information on TB therapy initiation and medications prescribed.

  8. Incorrectly stating or failing to mention if the Patient Agreed to be on Directly Observed Therapy (DOT). This is vital for ensuring treatment adherence and success.

Mistakes on the Hospital Discharge Approval Request Form can hinder a patient's transition from hospital to home or another care facility. Careful, thorough completion of the form is essential for a smooth discharge process.

Documents used along the form

When a patient is being discharged from the hospital, various documents and forms in addition to the Hospital Discharge Papers form are utilized to ensure a smooth transition from hospital care to home care or another facility. These documents serve multifaceted purposes, from detailing care plans to ensuring that financial obligations are met. Understanding each of these documents can help patients and their families navigate post-hospital care more effectively.

  • Post-Discharge Care Plan: This document outlines the patient's care requirements after leaving the hospital. It includes medication schedules, dietary restrictions, follow-up appointments, and any physical therapy or rehabilitation plans. It acts as a guide for both the patient and caregivers to manage care at home effectively.
  • Patient Handoff Checklist: Used mainly for transitions between care providers, this checklist ensures that all relevant patient information is communicated effectively to the next care provider, whether that is a nursing home, a rehabilitation center, or home health care service. It includes medication lists, recent labs, and special care instructions.
  • Medication Reconciliation Form: This form provides a comprehensive list of the medications a patient is taking upon discharge, including dosages and scheduling. It helps prevent medication errors and ensures continuity of care. The form is essential for review during follow-up medical appointments.
  • Home Health Care Setup Form: For patients needing home health care, this form initiates the process of arranging home health services. It outlines the services required, such as nursing care, physical therapy, or assistance with daily living activities. This ensures that the patient receives the necessary support for recovery at home.
  • Advanced Directive Form: Although not always directly related to the discharge process, if not previously provided, this is an appropriate time to ensure that an Advanced Directive or Living Will is in place. These documents express the patient's wishes regarding medical treatment in situations where they are unable to communicate those wishes themselves.
  • Insurance Claims Forms: These forms are necessary for the billing process, ensuring that the hospital stay and any post-discharge care are covered by the patient’s insurance provider. They may include authorizations for specific treatments or prescriptions filled upon discharge.

Each of these documents plays a crucial role in ensuring that patients receive the care and support they require after leaving the hospital. They facilitate communication between health care providers, patients, and caregivers, aiming to prevent readmissions and promote a smooth recovery. By understanding and properly utilizing these forms, all parties can work together more effectively towards the patient's health and well-being.

Similar forms

  • Prescription Medication Forms: Similar to the treatment information section in the Hospital Discharge Papers, Prescription Medication Forms detail the specific medications a patient needs, their dosages, and the frequency of administration. Both types of documents are critical for managing a patient’s treatment post-discharge and ensuring continuity of care.

  • Medical Referral Forms: These forms are used when a patient needs to see a specialist or get a specific type of medical care after being discharged. The patient follow-up appointment section in the Hospital Discharge Papers serves a similar purpose by specifying the date and details of the patient’s next appointment, including which physician will be assuming care.

  • Patient Transfer Forms: When a patient is moved from one facility to another, for reasons such as requiring specialized care, Patient Transfer Forms are used to detail the move. This is akin to the hospital discharge document specifying where the patient will be discharged to, whether it’s home, a skilled nursing facility, or another type of facility.

  • Emergency Contact Forms: These forms collect information about whom to contact in case of an emergency, similar to the patient contact information section in the Hospital Discharge Papers, which includes an emergency contact name, relationship to the patient, and telephone number, ensuring the hospital has someone to reach out to if necessary post-discharge.

  • Laboratory Test Results Forms: These documents report the findings of medical tests, much like the laboratory results section of the Hospital Discharge Papers. They play an integral role in informing the ongoing treatment of the patient by detailing specific test results, such as the acid fast bacilli (AFB) smear results for tuberculosis.

  • Treatment Plan Documents: These outline a comprehensive approach to a patient's healthcare after discharge, including medications, therapy, and follow-up appointments. The treatment information and patient follow-up appointment sections of the Hospital Discharge Papers provide similar critical details, ensuring the patient and their future healthcare providers understand the post-discharge care plan.

  • Patient Information and History Forms: Typically filled out during a patient’s first visit to a medical facility, these forms compile a patient's medical history, allergies, and previous treatments. The patient contact information section of the Hospital Discharge Papers collects somewhat similar details, focusing on current contact information to ensure the patient can be reached for follow-up care.

  • Communicable Disease Reporting Forms: Required for reporting cases of diseases like tuberculosis to the appropriate public health authorities, these forms are specifically mentioned in the context of the discharge papers. They are essential for public health monitoring and share a purpose with the discharge form, which, in this case, also involves notifying the health department before discharging a patient with a communicable condition like tuberculosis.

Dos and Don'ts

When filling out the Hospital Discharge Papers form, it is essential to follow specific guidelines to ensure the smooth transition of care and adherence to legal and health requirements. Here is a list of dos and don’ts that can help in correctly completing the form:

  • Do ensure that all sections of the form are completed in full. Incomplete forms may delay the discharge process and the patient's access to necessary post-discharge services.
  • Do double-check the patient's contact information in Section A for accuracy. Correct phone numbers and addresses are crucial for follow-up appointments and emergency contacts.
  • Do provide detailed discharge information in Section B. This includes accurately naming the discharging facility and the destination after discharge, whether it's the patient’s home, a shelter, or another facility.
  • Do list any potential barriers to TB therapy adherence in Section C. Identifying these barriers early can help healthcare providers address them promptly.
  • Do not forget to include all necessary laboratory results in Section D, including the dates and results of the three most recent acid-fast bacilli (AFB) smears. This information is critical for assessing the patient's progress.
  • Do accurately record all medication information in Section E, including the start date of TB therapy, any interruptions, and specifics about the medication dosages and frequencies.
  • Do not submit the form without the signature of the responsible physician at the discharging facility. The form must be signed and include the physician’s license number and contact information for validation.
  • Do fax the completed form to the designated number provided by the Health Department without delay, especially if the discharge is planned for a weekend or holiday.

Remember, proper completion and timely submission of the Hospital Discharge Approval Request Form are crucial for ensuring that patients receive the appropriate follow-up care and support post-discharge, especially for those with infectious conditions like TB. Following these guidelines can contribute to a smoother transition for the patient and comply with public health requirements.

Misconceptions

There are several common misconceptions about the Hospital Discharge Papers form, specifically the one used by the New York City Department of Health and Mental Hygiene for tuberculosis (TB) control. Understanding these can help clarify its purpose and importance in the public health system.

  • Misconception 1: The form is only for the hospital's internal use. In reality, the form is a crucial communication tool between the hospital and the NYC Department of Health and Mental Hygiene to ensure that patients with infectious TB are properly managed after discharge, protecting public health.

  • Misconception 2: TB control is the sole responsibility of the hospital. While hospitals play a key role in treatment, successful TB control is a cooperative effort. By using the discharge approval request form, hospitals coordinate with public health authorities to ensure continuity of care and adherence to therapy after discharge.

  • Misconception 3: All patients are treated the same on the discharge form. The form requires detailed information about the patient, including potential barriers to TB therapy adherence, reflecting an individualized approach to each patient’s care post-discharge.

  • Misconception 4: Completing the form is optional. As of June 16, 2010, Article 11 of the New York City Health Code mandates health care providers to obtain approval from the DOHMH before discharging infectious TB patients from the hospital, making the completion and submission of this form a legal requirement.

  • Misconception 5: The form doesn't need to be complete if the patient is feeling better. Regardless of the patient's condition at discharge, the form must be fully completed to ensure that all necessary information is provided for the patient's continued care and public safety.

  • Misconception 6: The form is only about medication. While medication details are critical, the form also covers other aspects of patient care, including follow-up appointments and potential barriers to care, underscoring a holistic approach to TB treatment.

  • Misconception 7: The discharge form is a substitute for direct communication with the health department. The form is an essential part of the communication process, but it does not replace the need for direct communication between hospital staff and public health officials, especially if there are questions or special circumstances.

  • Misconception 8: Information on the form is only relevant to healthcare providers. While healthcare providers are the primary users of the form, the collected information can be crucial for the patient and public health authorities, as it helps in the ongoing management and control of TB.

Clearing up these misconceptions helps emphasize the importance of the Hospital Discharge Papers form in controlling TB and ensuring patients receive the necessary follow-up care after leaving the hospital.

Key takeaways

Understanding the Hospital Discharge Approval Request Form is vital for ensuring a smooth transition for patients being treated for tuberculosis. Here are seven key takeaways to remember when completing and using this form:

  • The form must be filled out completely and faxed to the specified number at least 72 hours before the planned discharge date to ensure timely review and approval from the New York City Department of Health & Mental Hygiene (DOHMH).
  • It is mandatory for health care providers to obtain approval from the DOHMH before discharging infectious tuberculosis patients from the hospital. This is in accordance with Article 11 of the New York City Health Code.
  • For weekday (non-holiday) discharges, the discharge plan must be submitted during business hours (8am-5pm) for a review within 24 hours. Providers will be notified of approval or if additional information is required.
  • Providers planning to discharge patients on weekends or holidays should make all arrangements in advance, anticipating that the approval process might differ during these times.
  • Key sections of the form include patient contact information, discharge information, patient follow-up appointment details, laboratory results, and treatment information. Each section collects critical information ensuring continuity of care post-discharge.
  • In addition to completing the discharge form, health care providers are required to report all suspected or confirmed TB cases to the Health Department. This form does not substitute the mandatory communicable disease reporting requirements.
  • Patient adherence to TB therapy post-discharge is crucial. The form acts as a comprehensive tool to communicate with the physician assuming care of the patient, detailing potential barriers to therapy adherence and ensuring a seamless transition.

By adhering to these guidelines, health care providers can contribute to better health outcomes for tuberculosis patients and comply with public health mandates. Filling out the Hospital Discharge Approval Request Form meticulously and understanding its importance is key to the organized and responsible care of infectious TB patients.

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