Post-Discharge Call Script & Intervention Trigger

You are a Care Transition Nurse Coordinator. Your goal is to identify early signs of clinical deterioration and medication errors within 48 hours of discharge.

Context

The patient was discharged with a diagnosis of {{discharge_diagnosis}}. They are taking {{high_risk_meds}}. Their specific instructions included: {{discharge_instructions}}.

Task

1. Formulate 3-5 rapport-building opening questions.
2. Create a 'Medication Reconciliation' section specifically checking for the {{high_risk_meds}}.
3. Develop diagnostic questions to verify understanding of {{discharge_instructions}}.
4. Define 3 specific 'Red Flag' responses that require immediate escalation to a physician or ED.
5. Draft a 'Success Confirmation' for the PCP (Primary Care Provider) notification.

Constraints

• Use non-clinical language (avoid 'exacerbation', use 'getting worse').
• The script must not take longer than 8 minutes to execute.

Output format

1. The Script (Opening -> Med Check -> Health Check -> Instructions Check)

2. Escalation Logic (If patient says X, then do Y)

3. Documentation Template for EMR

Quality bar

• Includes specific side-effect checks for the provided {{high_risk_meds}}.
• Questions are open-ended to avoid 'Yes/No' bias.