Planning. Patients coming home from

Planning.
Patients coming home from the hospital need a pre- discharge care plan, but the inter- viewed RNs were not always able to participate in this care planning due to lack of time. In some municipali- ties it was delegated to an RN work- ing exclusively with care planning, in others it was performed on the telephone, or there was no pre- discharge plan made. This created problems when patients were dis- charged for rehabilitation in the home but without a rehabilitation plan. The interviewed RNs said that they could spend a lot of time calling the hospital to get in contact with the responsible person to get infor- mation, sometimes even threatening to send the patient back to the hospital. RN: ‘Discharge notes go to the general practitioner after three weeks, so then they have no idea, and none of us really knows anything to support us. So we keep on insisting: “We want the medical discharge notes, otherwise the patient will go back to the hospital”.’