Table 2

Example of goals for discharge-ready from medical, nursing, physiotherapy, and occupational perspectives

Goals medicineGoals physiotherapyGoals occupational therapyGoals nursing
The infection markers are decreasingThe patient must have a functioning locomotionAssessment of the need for occupational therapy must be done and documented in the patient’s journalNursing actions have been started based on what is reasonable to achieve during the hospital stay
The hemoglobin level is increasingThe patient should have as independent locomotion as possible in relation to previous abilities and current preconditionsThe patient should become as independent as possible in their everyday activities of daily living. A report is done to external caregivers according to the continued plan for everyday activities in daily life and the need of aidA plan for the follow-up for the nursing actions after discharge must be ready
AfebrileThere should be an assessment and a plan for the external follow-up. The digital planning system for external caregivers must be updatedAdequate aid is safely prescribed or reported to external caregivers for follow-upThe patient and relatives must be informed and involved during the discharge process
The wound heals as expected  The nurses have the final responsibility to certain that the patients have all necessary papers, information, and drugs when being discharged
Test results and vital signs normalizes (expected) or are within the patient’s normal range. Not acute, remaining pathology, is referred further   
The patient is symptom-free   
The pharmaceutical prescription is updated   

Source(s): Authors’ own work

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