Rx Transition
Prescribing Safe Transitions in Care

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1. Discharge preparation Done

Give patient (and/or caregivers) the Discharge Planning Checklist. This should be timed so that the patient is able to read through it and provide written answers, ideally at least one day before discharge. It is also ideal to have a version of this document in the patient's native language.

2. Discharge survey Done

Before discharge you should complete the Discharge Survey (select tab above). This is done together with the patient, using the Discharge Planning Checklist as a guide.

3. Text message follow-ups Done

You choose follow-up questions that can be sent automatically on specified dates. They are delivered by SMS text message to the patient's (or care giver's) phone. Each message also includes instructions for the patient, which is to call a certain phone number if the answer to the specified question is abnormal. For example, if they see a certain symptom.

4. Phone follow-ups Not done

Like the text message follow-ups, these can be added at the time of discharge and at any later date. Each one has an associated date, for advance scheduling. On the appointed date, an email is sent to you as a reminder, with a link back to this tool so you can carry out the follow-up call. You can also record the results of the call here.

This survey is to be completed by the nurse before discharge.

This form is empty until you choose a patient on the first tab.

These are follow-ups for you to conduct by phone.
  • Schedule them in advance, such as upon discharge. Also enter the contact information and follow-up plan.
  • You will get an email reminder on the day of the scheduled follow-up.
  • Return here to record the results of the follow-up. If you spoke with a different person or on a different day than the plan, then enter that too.
This is empty until you choose a patient on the first tab.

At discharge, make a list of follow-up questions to send by text message to the patient on the days you indicate. You can choose suggestions from the list, write your own questions, or both.

To make your selections, simply enter the date next to each message you want to schedule.

This is empty until you choose a patient on the first tab.





Write in your question or advice in a box, along with a date.

This page is empty until you choose a patient on the first tab.

This page details the correspondence sent from the system to the providers and patients.

Text messages sent to this patient

(none yet)

Email reminders sent to care provider

(none yet)