The Hospital Discharge Papers form, specifically designed for the New York City Department of Health and Mental Hygiene's Bureau of Tuberculosis Control, is an essential document that must be completed and faxed to the department prior to the discharge of any patient diagnosed with infectious tuberculosis. This form collects critical information ranging from patient contact details and discharge information to follow-up appointments and treatment details, ensuring a safe and coordinated transition from hospital care. For those in need of guidance on filling out this form, a button below offers the necessary instructions and support.
Navigating the complexities of hospital discharges, particularly for patients with infectious diseases like tuberculosis (TB), requires thorough documentation and adherence to specific protocols to ensure public health and patient safety. In New York City, the Department of Health and Mental Hygiene mandates health care providers to seek approval before discharging patients diagnosed with infectious TB. This process is facilitated through the use of the Hospital Discharge Approval Request Form (TB 354), a detailed document that records essential patient information, the discharge plan, and post-discharge care instructions, among other critical data. The form serves multiple purposes: it provides a structured means for health care providers to submit discharge plans for review, ensures continuity of care for the patient, and helps public health officials monitor and control the spread of TB. Completing the form involves detailing the patient's contact information, discharge information, follow-up appointments, laboratory results, and treatment information. It requires coordination between various health care professionals to fill out and submit the form accurately and timely, adhering to the guidelines set forth by the Bureau of Tuberculosis Control. This procedure not only safeguards the health of the patient but also contributes to the broader goal of managing TB in the community.
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 crucial step in ensuring the safety and well-being of patients diagnosed with tuberculosis (TB), as well as the community at large. This form is part of a mandatory process established to control the spread of infectious TB in accordance with the New York City Health Code. Completing this form attentively and submitting it to the New York City Department of Health and Mental Hygiene (DOHMH) is essential for securing approval for the patient's discharge. Here is a step-by-step guide to accurately complete and submit this form.
Upon successful submission, the Bureau of TB Control will review the discharge plan. Within 24 hours on weekdays, the provider will be notified of the approval status or if further information is required. It's imperative to arrange all discharge details in advance, especially for discharges planned over weekends or holidays to ensure continuity of care and adherence to public health protocols. For any queries related to completing the form or TB case reporting, contacting the Bureau of Tuberculosis Control via the 311 service is advised.
What is the purpose of the Hospital Discharge Approval Request Form?
The Hospital Discharge Approval Request Form, also referred to as TB 354, is a document that health care providers must complete and submit to the New York City Department of Health & Mental Hygiene prior to discharging a patient with infectious Tuberculosis (TB) from the hospital. The form ensures that the Department approves of the patient's discharge plan, aiming to support public health and safety.
When should the Hospital Discharge Approval Request Form be submitted?
Health care providers are required to submit the form at least 72 hours before the anticipated discharge date of a patient with infectious TB. This allows sufficient time for the Department of Health & Mental Hygiene to review and approve the discharge plan or to request additional information if necessary.
How is the Hospital Discharge Approval Request Form submitted?
The form should be completed in full and then faxed to the Bureau of Tuberculosis Control at 347-396-7579. Ensure all sections of the form are accurately filled out to avoid delays in the approval process.
What information is needed in Section A of the form?
Section A requires the patient's contact information, including the patient’s name, a verified address, telephone numbers, and an emergency contact's name, relationship to the patient, and telephone numbers.
What details must be included in Section B regarding discharge information?
In Section B, you must provide the discharging facility's name and contact number, the patient's medical record number, dates of admission and planned discharge, and the location to which the patient is being discharged. If the patient is to be discharged to a different location than the one listed, additional address and contact information for that location is required.
What information is required in Section C regarding patient follow-up?
Section C calls for details about the patient’s follow-up appointment, including the date, the physician assuming care, and their contact information. It also asks for potential barriers that might affect the patient's adherence to TB therapy.
What does Section D cover?
Section D pertains to the laboratory results of the three most recent acid fast bacilli (AFB) smears, including specimen collection dates, sources, and results or grades of the AFB smear tests.
What is the focus of Section E on treatment information?
Section E requests detailed information on the TB treatment initiated, including the date started, any interruptions in therapy (along with reasons and duration), specific medications and dosages, treatment frequency, and whether a central line was inserted. This section also asks if the patient will have medications supplied at discharge and if they agreed to be on directly observed therapy (DOT).
Who needs to complete and sign the Hospital Discharge Approval Request Form?
The form should be completed by a healthcare provider familiar with the patient's treatment plan, and it must be signed by the responsible physician at the discharging facility. The physician’s signature, print name, license number, and contact information are required for submission.
What happens after the form is submitted?
After submission, Bureau of TB Control staff will review the discharge plan. Within 24 hours on weekdays, they will either notify the provider of approval or request additional information or actions required for approval.
Is the Hospital Discharge Approval Request Form the only requirement for discharging a TB patient?
No, the form is part of a broader protocol for the safe discharge of infectious TB patients. Health care providers must also adhere to the New York City Health Code, Article 11, which includes obtaining discharge approval from the Department of Health & Mental Hygiene and ensuring proper communicable disease reporting through Reporting Central.
Filling out hospital discharge papers can often feel like navigating through a maze of boxes and fields, particularly when dealing with specific forms like the New York City Department of Health and Mental Hygiene's TB Hospital Discharge Approval Request Form. Among the common errors individuals make, one stands out: incomplete filling of Section A, which pertains to patient contact information. Adhering to every detail is critical, such as providing both requested telephone numbers and accurately noting the patient's address. This foundational step ensures that subsequent care or follow-up processes proceed without unnecessary hitches. Yet, it's frequently overlooked or filled out in haste, leading to potential gaps in post-discharge care.
Another notable misstep occurs in Section B, which requires details about the discharging facility and discharge information. Oftentimes, individuals neglect to specify the correct discharging facility's phone number or the precise location to which the patient will be discharged. This part of the form is crucial for ensuring the patient's smooth transition from the hospital to their next destination, be it home, a skilled nursing facility, or any other place. Such oversights can delay discharges or cause confusion regarding patient placement post-discharge.
Mistakes in Section C, involving patient follow-up appointment information, can also derail the discharge process. Entries often fall short when listing potential barriers to TB therapy adherence, such as homelessness or physical disabilities. This information is vital for tailoring follow-up care to the patient's specific needs, yet it is frequently underreported or altogether missed. Identifying and anticipating these barriers early on allows healthcare providers to implement necessary interventions, minimizing the risk of TB treatment interruption.
Lastly, inaccuracies or omissions in Section E, which deals with treatment information, represent a significant error. Critical information such as the TB medications prescribed at discharge, treatment frequency, and whether a central line (i.e., PICC) was inserted can be incompletely filled or overlooked. This section is particularly important for ensuring continuity of care and preventing TB therapy interruptions. Any mistake here can lead to serious health implications for the patient, underscoring the need for meticulous attention to detail when completing this form.
When a patient is discharged from the hospital, especially in cases involving infectious diseases like tuberculosis, it's crucial to ensure a seamless transition from hospital care to self-care or another care facility. This often involves documentation that goes beyond the Hospital Discharge Papers. These forms and documents play a vital role in providing continuous care, ensuring legal compliance, and maintaining the health and safety of the patient and the public. Here is a list of seven other forms and documents that are frequently used alongside Hospital Discharge Papers.
Properly managing the discharge process with these additional forms and documents helps ensure that the patient's transition from hospital to home or another facility is smooth and that their care continues without interruption. This not only supports the patient's recovery and health but also minimizes the risk of readmission due to inadequate post-discharge care. Healthcare providers must be diligent in completing and distributing these documents to all relevant parties to facilitate coordinated care and comply with healthcare regulations.
The Medical Release Form is quite similar to the Hospital Discharge Approval Request Form, especially in the requirement for detailed patient information. Both documents contain sections requesting specific personal data, such as the patient's name, contact details, and the name and telephone number of an emergency contact. Like the discharge form, the medical release form is used to formalize the process of transferring responsibility for a patient, either from one facility to another or from a facility back to the patient or their caregiver, ensuring all necessary medical information is communicated effectively.
The Patient Transfer Form echoes the discharge form in its function to coordinate the movement of patients between facilities. It includes crucial details about the discharging and receiving facilities, much like the discharge form specifies where the patient will be going after leaving the hospital. Both forms are pivotal in ensuring seamless care transitions, detailing medical and personal information to prevent any lapses in care, whether the patient moves to another health facility, home, or another specialized care setting.
A Prescription Form, while more focused on medication than the broad scope of a Hospital Discharge Approval Request Form, shares the emphasis on detailed treatment information. The discharge form's section on TB therapy, for example, details the medication regimen including dosages and frequencies. Both types of forms serve as crucial communication tools between healthcare providers and pharmacies or other care providers, ensuring that a patient's medication needs are clearly understood and appropriately managed post-discharge.
The Advanced Directive Form, or Living Will, differs in purpose but is similar in its patient-centric approach. Like the discharge form, it captures critical, individualized patient desires and medical details, albeit focused on end-of-life care preferences rather than immediate post-discharge care. Both documents require careful, explicit documentation of the patient's health status and care preferences, ensuring that healthcare providers respect the patient's wishes in either scenario.
When filling out the Hospital Discharge Approval Request Form for tuberculosis (TB) patients in New York City, it's crucial to approach the task with diligence and precision. Here are six dos and don'ts that should guide you through the process:
Dos:
Ensure accuracy: Double-check all the information you provide, especially patient contact details, discharge information, and TB treatment specifics. Accurate data is pivotal for effective follow-up and care.
Complete every section: Do not leave any section blank. If a particular section does not apply, make sure to note it appropriately. Incomplete forms could delay the discharge process.
Include updated laboratory results: Always provide the most recent acid fast bacilli (AFB) smear results. This information is critical for understanding the patient's current condition.
Detail the TB treatment plan: Clearly indicate the medications, dosages, and treatment frequency. This data ensures continuity of care and adherence to the TB therapy post-discharge.
Specify potential barriers to therapy adherence: Identifying and documenting obstacles upfront can assist healthcare providers in creating a more effective post-discharge plan for the patient.
Fax the completed form promptly: To prevent any delays in the discharge process, fax the form to the Department of Health and Mental Hygiene at 347-396-7579 as soon as possible.
Don'ts:
Don't rush through the form: Taking your time to carefully fill out the form can prevent mistakes that might delay the discharge approval.
Don't leave out the emergency contact: Providing a reliable emergency contact is crucial for any post-discharge needs or follow-ups required.
Don't omit treatment interruptions: If the patient experienced any interruptions in their TB treatment, provide detailed reasons and durations. This information is essential for assessing patient care continuity.
Don't forget to print names clearly: Ensure that both the individual filling out the form and the responsible physician at the discharging facility print their names clearly to avoid any confusion.
Don't assume approval: Remember, submitting the form does not guarantee immediate approval. The health department will review the form and may request additional information.
Don't neglect to check for travel plans: Indicating whether the patient is scheduled to travel outside of NYC is crucial for public health monitoring and planning.
There are several misunderstandings regarding the Hospital Discharge Papers form, particularly the version used by the New York City Department of Health and Mental Hygiene for tuberculosis control. Let's debunk ten common misconceptions:
Understanding these aspects of the Hospital Discharge Approval Request Form helps clarify its purpose and requirements, ensuring better compliance and contributing to effective public health management.
Understanding the ins and outs of the Hospital Discharge Approval Request Form (TB 354) is crucial for health care providers dealing with tuberculosis (TB) patients in New York City. Here are some key takeaways to ensure its correct use and compliance with the New York City Department of Health & Mental Hygiene (DOHMH) guidelines:
Comprehensively filling out and submitting the Hospital Discharge Approval Request Form (TB 354) plays an essential role in the management and treatment of TB patients. By ensuring each section is accurately completed and that the form is submitted in a timely manner, health care providers can facilitate better outcomes for their patients while adhering to public health protocols.
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