Admission and Discharge Checklist
VTE prophylaxis, medication reconciliation, discharge checklist, and Choosing Wisely admission tests.
VTE Prophylaxis
Hospital-associated VTE is the most common preventable cause of hospital death. Risk-stratify every patient on admission using a validated tool and order prophylaxis (or document a contraindication) per Joint Commission core measures (AHRQ VTE Guide).
Padua Prediction Score (Medical Inpatients)
Score >= 4 = high risk. See Primary Care Scores for calculator links.
| Risk Factor | Points |
|---|---|
| Active cancer (metastatic or treated within 6 months) | 3 |
| Prior VTE (excluding superficial vein thrombosis) | 3 |
| Reduced mobility (bedrest > 3 days with bathroom privileges) | 3 |
| Known thrombophilia (factor V Leiden, prothrombin mutation, antiphospholipid, etc.) | 3 |
| Recent trauma or surgery (within 1 month) | 2 |
| Age >= 70 years | 1 |
| Heart or respiratory failure (NYHA III-IV, COPD exacerbation) | 1 |
| Acute MI or ischemic stroke | 1 |
| Acute infection or rheumatologic disorder | 1 |
| Obesity (BMI >= 30) | 1 |
| Ongoing hormonal treatment (oral contraceptives, HRT, tamoxifen) | 1 |
Caprini Score (Surgical Patients)
| Risk Tier | Score | Prophylaxis Recommendation |
|---|---|---|
| Very low | 0 | Early ambulation only |
| Low | 1-2 | Mechanical prophylaxis (IPC) |
| Moderate | 3-4 | Pharmacologic (LMWH or UFH) or mechanical if bleed risk high |
| High | >= 5 | Pharmacologic + mechanical combined |
Prophylaxis by Risk Tier
| Risk Level | Recommendation | Regimen |
|---|---|---|
| Low risk (Padua < 4, Caprini 1-2) | Early ambulation; mechanical if immobile | N/A |
| Moderate risk (Caprini 3-4) | Pharmacologic prophylaxis | Enoxaparin 40 mg SC daily or UFH 5000 units SC q12h |
| High risk (Padua >= 4, Caprini >= 5) | Pharmacologic + mechanical | Enoxaparin 40 mg SC daily (or 30 mg BID if obese) + IPC |
| Very high risk (active cancer + prior VTE, major orthopedic) | Extended-duration pharmacologic | Enoxaparin 40 mg SC daily x 28-35 days or rivaroxaban/apixaban per protocol |
Contraindications to Pharmacologic Prophylaxis
- Active bleeding or recent major bleeding (especially intracranial or spinal)
- Coagulopathy: INR > 1.5, aPTT > 2x normal, platelets below 50,000
- Recent high-bleed-risk surgery (neurosurgery, spine)
- History of HIT (heparin-induced thrombocytopenia)
- Severe renal impairment (CrCl below 30) — LMWH contraindicated or dose-reduced
- Epidural or spinal catheter (hold until catheter removed)
Medication Reconciliation
Medication discrepancies at transitions of care are a leading cause of adverse drug events. Use the AHRQ MATCH toolkit approach (AHRQ MATCH).
Admission Med Rec
- Obtain the best possible medication history (BPMH) — interview patient, caregiver, pharmacy, and PCP
- Compare BPMH to admission orders
- Document and resolve all discrepancies with the ordering provider
- Pay special attention to high-risk medication classes:
| High-Risk Class | Key Checks |
|---|---|
| Anticoagulants (warfarin, DOACs, LMWH) | Indication, dose, last dose time, hold vs continue, bridging plan |
| Antiplatelets (aspirin, clopidogrel, ticagrelor) | Indication, hold vs continue (especially pre-procedure) |
| Insulin and oral hypoglycemics | Home regimen, hold vs adjust (NPO, steroids, renal function) |
| Antiarrhythmics (amiodarone, sotalol, digoxin) | Level, QTc, renal function, drug interactions |
| Antiseizure medications | Level, hold vs continue (NPO — convert to IV) |
| Immunosuppressants (tacrolimus, cyclosporine, mycophenolate) | Level, hold vs continue, infection risk |
| Chronic steroids | Stress-dose protocol if indicated |
| Opioids | Home dose, tolerance, MME, naloxone co-prescribing |
Discharge Med Rec
- Compare the inpatient medication list to the pre-admission home list
- Identify each change as intentional (dose adjusted, held, stopped, new start) or unintentional
- Document the reason for every change in the discharge summary
- Provide the reconciled list to the patient and the follow-up provider
- Highlight medications that require monitoring (INR for warfarin, glucose for insulin, renal function for DOACs)
Teach-Back
After providing the medication list, ask the patient to explain it back: “Tell me what you will take, when, and how much.” Patient understanding is confirmed when they can explain it correctly. 40-80% of medical information is forgotten immediately, and nearly half of retained information is incorrect (AHRQ MATCH).
Discharge Checklist
Based on the AHRQ Re-Engineered Discharge (RED) Toolkit (AHRQ RED), which reduced readmissions and post-hospital ED visits in controlled trials.
RED Components
| Step | Action | Done |
|---|---|---|
| 1. Med rec | Reconciled medication list completed and given to patient | [ ] |
| 2. Follow-up | Follow-up appointment scheduled before discharge (who, when, where) | [ ] |
| 3. Patient education | Diagnosis, medications (name, dose, purpose, side effects), and warning signs reviewed | [ ] |
| 4. Discharge summary | Summary completed and sent to follow-up provider within 48 hours | [ ] |
| 5. Teach-back | Patient or family demonstrates understanding of the plan | [ ] |
| 6. Post-discharge call | Post-discharge phone call scheduled within 48-72 hours | [ ] |
Discharge Red Flags (What to Tell the Patient)
Call the clinic or return to the ED for:
- Fever, shortness of breath, or chest pain
- Worsening pain, bleeding, or swelling
- Inability to tolerate oral medications
- Confusion or change in mental status
- New or worsening symptoms related to the discharge diagnosis
Clarify when to call 911 versus call the clinic.
I-PASS Handoff
The I-PASS structured handoff bundle reduced medical errors by 23% and adverse events by 30% in a multicenter study of 10,740 admissions (I-PASSI-PASS Handoff Study · 2014 · N Engl J MedMulticenter implementation of the I-PASS bundle reduced medical errors by 23% and preventable adverse events by 30%.View source ↗). Use it for every transition of care, including admission-to-team and team-to-discharge handoffs. See Resources by Technique for the full I-PASS framework.
Readmission Risk Scores
See Primary Care Scores for LACE Index and HOSPITAL Score calculator links.
Choosing Wisely: Low-Value Admission Tests
The ABIM Choosing Wisely initiative identified common tests and procedures that provide little value in hospitalized patients. See Choosing Wisely for the full society list catalog.
Tests to Question on Admission
| Test or Procedure | When to Question | Better Approach |
|---|---|---|
| Daily morning labs (CBC, BMP) | Hemodynamically stable patient without expected management change | Order only when results will change management |
| Type and screen | Same-day procedure without crossmatch history | Order only if transfusion is likely |
| Pre-op EKG | Low-risk surgery per ASA guidelines | Omit unless indicated by history or exam |
| Pre-op CXR | No cardiopulmonary symptoms or exam findings | Omit unless indicated by history or exam |
| Standing antipyretics | Febrile patient without symptoms | Treat symptoms, not the number; fever is a clinical sign |
| Urine culture | No urinary symptoms | High rate of asymptomatic bacteriuria leading to unnecessary antibiotics |
| Chest X-ray for CHF | Recent prior CXR with no clinical change | Omit unless clinical status has changed |
| Peripheral IV line | No planned IV therapy | Do not place solely for access |
| Sliding-scale insulin without basal | Any patient with hyperglycemia | Add basal insulin per ADA Standards of Care |
| Red cell transfusion | Hemoglobin above 7-8 g/dL in stable patient | Transfuse for symptoms or below threshold per clinical status |