Hospital admission

Request a HIPAA authorization form. Update at every shift change.

Patient portal

Ask hospital admitting

Most hospitals will set up portal access during the stay if you ask.

First hours - Medications

What about my home medications

Hospital pharmacies do not stock every medication and substitute liberally. Some substitutions are fine; some are problematic; some can cause real harm. Knowing which is which prevents medication errors that account for a meaningful share of hospital harm.

Bring a current medication list

Ideally written, with each medication name, dose, frequency, and reason. If you cannot bring a list, bring the bottles. The hospital will reconcile your home medications against what they want to order. Without an accurate list, this fails.

Generic substitution is normal

The hospital pharmacy almost always substitutes brand names for generics. Most generic substitutions are clinically equivalent. Some patients tolerate one generic better than another, especially with seizure medications, thyroid medications, and certain heart medications. If you have had a problem with a specific generic, tell the team.

Some home medications get stopped

Anticoagulants (blood thinners), some blood pressure medications, and certain diabetes medications are commonly stopped on admission. Sometimes this is appropriate; sometimes it gets forgotten when you go home. Ask: "Which home medications are you stopping? Are they being restarted before discharge?"

IV vs oral

Hospitalized patients often get medications IV when they would normally take them orally. This is sometimes necessary, sometimes default. Ask if oral is acceptable - it is more comfortable and easier to continue at home.

PRN vs scheduled

Pain medications are often ordered PRN (as needed) which means you have to ask for them. If your pain is constant, ask whether scheduled dosing would work better than PRN.

Discharge medication list

Before discharge, you should receive a written medication list showing exactly what to take, what was changed, and what was stopped. Compare it to your home list. Do not assume your home medications resume automatically - some intentionally do not.

The medication errors that hurt people are usually quiet ones

Most serious medication problems do not come from the wrong drug at the wrong dose, which gets caught. They come from things forgotten in the transition: a home medication not restarted, a hospital medication continued unnecessarily, two medications with the same effect both being prescribed. Reconcile your full list at discharge, not just the new prescriptions.

Medical team - Hospitalist

What is a hospitalist

In modern American hospital practice, most medical patients are managed by hospitalists rather than their primary care doctors. Understanding why, and how to work with them, makes for better hospital care.

Hospitalists are physicians who work exclusively in the hospital

They typically work 7-day shifts during which they manage 12-20 patients. They are usually trained in internal medicine and have specific expertise in acute hospital care.

They replaced the old model where PCPs rounded on their own patients

Twenty years ago, your community internist would round on you in the hospital before going to clinic. That model has largely disappeared. Hospital medicine is now a recognized subspecialty.

They are dedicated to hospital care

A hospitalist is in the hospital all day. They can see you multiple times if your condition changes. They have time to coordinate with consultants. This is their primary advantage over the old model.

They rotate every 3-7 days

Most hospitalist groups work shifts. The hospitalist who admits you may not be the one managing you on day 4. Handoffs between hospitalists are when continuity gets lost. Ask each new hospitalist: "What did you read about my case in the handoff?"

Communication with your PCP is the weak link

Your community PCP gets a discharge summary after you go home. Sometimes it is timely; sometimes it is delayed by weeks. If you can, ask the hospitalist to call your PCP before discharge for any complex case.

They have less context about you than your PCP

A hospitalist meeting you for the first time does not know your baseline, your preferences, or your history beyond what is in the chart. Tell them what they need to know. Bring a one-page summary if possible.

Medical team - Rounds

When do rounds happen

Rounds are the daily team visit when most decisions get made. Understanding how rounds work and being present when possible is one of the highest-leverage things a patient or family can do.

Rounds happen once a day, usually mornings

For hospitalists, rounds are typically between 7am and noon. For surgical services, often earlier (5-7am). For teaching services with residents, can take longer. Specific times vary by hospital, day of week, and patient acuity.

What happens during rounds

The team reviews overnight events, examines you, reviews lab/imaging results, discusses the plan, and writes orders. Decisions about discharge timing, medication changes, and consults all happen at rounds.

You can ask the nurse what time rounds will be

Tell the nurse: "I want to be awake and have my family on the phone for rounds. What time will the team come by?" Most experienced nurses can predict within an hour, especially after the first day.

Family-by-phone during rounds works

Speakerphone or a video call so a family member can hear and ask questions. Most teams accept this and many encourage it.

Asking for the team to return

If you missed rounds because you were asleep or family could not be present, ask the nurse to request a return visit. This usually requires waiting until the team has finished other patients but it can happen.

Teaching hospital rounds are different

At academic medical centers, rounds include the attending physician, the senior resident, junior residents, interns, and medical students. The discussion is often educational. The attending makes final decisions. Listen for who is talking and what their role is.

Have your questions written before rounds

The team is on a tight schedule. Two minutes of focused questions gets better answers than 20 minutes of rambling. Top three questions, written down. Share them with the nurse before rounds so the team has time to think.

Medical team - Hierarchy

Who are all these doctors

Teaching hospitals (academic medical centers) have a layered hierarchy of physicians at different training stages. Knowing who is who and who has authority for what helps you ask the right person the right question.

Medical students

Years 3 and 4 of medical school. Wear short white coats. Examine patients, present cases, write notes that get co-signed. They have no independent authority. Often have time to talk that other team members do not.

Interns

First-year residents (post-graduate year 1, "PGY-1"). Recently graduated from medical school. Write most of the orders. Round on you in the morning before the senior team. They are real doctors but newest in training.

Residents

Years 2-4 of residency depending on specialty. Manage day-to-day care, supervise interns. Have growing authority. The senior resident (PGY-3+) often runs rounds.

Fellows

Subspecialty trainees who have completed residency and are training in a narrower field (cardiology, oncology, etc.). They work alongside attendings, often see consults independently.

Attendings

Fully trained physicians with final responsibility for your care. The supervising attending is the doctor whose name appears on the legal medical record. They round daily but often briefly.

In a community (non-teaching) hospital

You will typically only have one attending and possibly a nurse practitioner or physician assistant. The hierarchy collapses. Decisions are simpler but you have fewer people thinking about your case.

Medical team - Specialists

Why is this specialist here now

When the hospitalist or admitting physician needs expertise they do not have, they consult a specialist. Knowing why a specialist was called, what their role is, and how their recommendations get implemented helps you participate.

Consultations are common

A typical medical admission may involve 1-3 specialist consultations. Cardiology, pulmonology, infectious disease, gastroenterology, neurology, surgery, palliative care, psychiatry are all common consultants.

The specialist evaluates and writes a recommendation

They examine you, review your chart, and write a consult note with their recommendations. The note appears in the medical record and is shared with the hospitalist.

The hospitalist decides whether to follow the recommendation

In American hospital practice, the consultant gives advice. The primary team (hospitalist) decides whether to follow it. This sometimes leads to recommendations not getting implemented because the hospitalist disagreed or considered it less urgent.

Ask the consultant directly

If a consultant comes by and tells you they recommend something, ask: "Have you discussed this with the hospitalist? When will they implement it?" If the answer is unclear, follow up with the hospitalist.

Multiple consultants can recommend conflicting things

When 2-3 specialists give conflicting recommendations, the hospitalist must reconcile. If you sense conflict, ask: "How are you weighing these different recommendations?" The hospitalist should be able to explain the reasoning.

You can request a specific consultation

If you believe you need a specialist who has not been called, ask the hospitalist. Be specific: "I have a complex cardiac history and would like cardiology to weigh in on this." A clear request usually gets honored.

Medical team - Nurses

Working with nurses

Nurses are at your bedside more than any other member of the medical team. They notice changes physicians miss. They have authority to escalate to the physician at any hour. Working with them well makes the entire stay better.

Nurses see you every 1-4 hours during the day

Vital signs, medication administration, assessment of how you are feeling. They are doing focused brief visits frequently. Tell them anything that has changed since their last check.

They notice subtle changes

A nurse who has been caring for you all shift will often notice a change in your color, breathing, or mental status before you or your family do. They are trained to recognize early signs of deterioration.

They have authority to call physicians

If a nurse believes a physician needs to evaluate you, they will call. The threshold for calling varies by nurse, hospital, and time of night. If you are concerned and the nurse seems to be considering whether to call, advocate for it.

Charge nurses run the unit

Each shift has a charge nurse who manages assignments, escalations, and unit issues. If you have a complaint about your nursing care, the charge nurse is the appropriate person to speak with.

Shift change is at 7am and 7pm

Most hospitals have 12-hour nursing shifts. The handoff between nurses happens at 7am and 7pm. Important information that does not get communicated at handoff can fall through the cracks. If something matters, repeat it to the new nurse.

Nurse staffing ratios matter

A typical medical-surgical floor nurse cares for 4-6 patients. A step-down or telemetry nurse cares for 3-4. An ICU nurse cares for 1-2. If you feel your needs are not being met, this is sometimes the reason. Ask the charge nurse if a different unit assignment is appropriate.

Medical team - Case manager

The case manager

Different from a doctor. Different from a nurse. The case manager (sometimes called discharge planner or care coordinator) plans what happens after the hospital. Most patients meet them too late. Meeting them on day one changes what is possible.

Their job is to plan discharge

The case manager identifies what services and equipment you will need after discharge, arranges them, and ensures the discharge is safe. This includes home health, durable medical equipment, skilled nursing facility placement, and follow-up appointments.

They are usually social workers or nurses

Most case managers are licensed social workers or nurses with additional case management training. Their role is administrative and clinical, not prescriptive. They cannot write orders but they can negotiate with insurance and arrange services.

They control what gets ordered for after discharge

Equipment delivery, home health agency choice, SNF placement, medical transportation - the case manager arranges all of these. If you want a specific home health agency or SNF, tell the case manager.

Most patients meet them on day before discharge

By then, most planning has already been done. Many of the choices you might have made are no longer available. Meeting the case manager on day one changes what is on the table.

Ask: "Can I meet the case manager today?"

Tell the nurse, the hospitalist, anyone. Be persistent. The hospital is required to have a discharge planning process; the case manager is the person executing it.

They can advocate for you with insurance

Insurance approval issues, prior authorization for post-acute placement, peer-to-peer reviews - the case manager often handles these. If insurance is denying something, ask the case manager what they are doing about it.

Connect with the case manager

Ask the nurse

Request a case manager meeting today, not later in the stay.

24/7. Questions about hospital discharge rights and post-acute coverage.

Status - Inpatient vs observation

Am I admitted or in observation

These two words look identical from a hospital bed but have completely different financial and coverage consequences. Understanding the distinction is the single most important thing you can know about a hospital stay.

Inpatient: Medicare Part A pays

You are formally admitted. Part A covers your room, nursing, drugs, and most services. After the Part A deductible ($1,736 in 2026), the first 60 days are covered in full. Critically, only inpatient days count toward the 3-day requirement for skilled nursing facility (SNF) coverage afterward.

Observation: Medicare Part B pays

You are technically still an outpatient even if you stay in a hospital bed for nights. Part B covers services with a 20% coinsurance and your usual Part B deductible. Drugs you take while in observation may not be covered, or may be covered only as self-administered drugs. Most importantly, observation days do not count toward SNF coverage.

How to find out your status

Ask the admitting physician directly: "Am I admitted as inpatient or observation?" Do not rely on the room number or whether you are in a hospital gown. Both inpatient and observation patients can be in the same kinds of rooms. Status is a billing classification, not a physical location.

You can ask repeatedly during the stay

Status can change. A patient may start as observation and be converted to inpatient. Or remain observation throughout. Ask each new shift if anything has changed.

What if the answer is unclear

Sometimes nurses or residents are not sure. The attending physician or hospitalist will know. The case manager will know. The patient access office (admission registration) will know. If you cannot get a clear answer, escalate.

The 3-day rule for SNF coverage is non-negotiable

Medicare Part A covers a SNF stay only if you had 3 consecutive days as a hospital inpatient (not counting the day of discharge) immediately before. Observation days do not count. Many families discover this only when the SNF bill arrives.

Get a clear answer on status

24/7. Ask about your status and your appeal rights.

Center for Medicare Advocacy

medicareadvocacy.org

Free legal advocacy for Medicare issues including observation status.

Status - Two-midnight rule

The two-midnight rule

CMS guidance generally directs hospitals to admit patients as inpatient when the doctor expects the stay to cross two midnights. When the expected stay is shorter, observation status is appropriate. The rule was designed to reduce gaming. It does not eliminate it.

The rule in practice

When the admitting physician expects a stay of at least two midnights, inpatient admission is generally appropriate. When fewer than two midnights are expected, observation status is appropriate. The expectation is documented at the time of admission.

Why the rule exists

Before 2014, observation status grew rapidly because hospitals could be financially penalized for inpatient admissions that auditors later said should have been observation. CMS adopted the two-midnight rule to provide clearer guidance.

Why it does not eliminate the problem

Observation has fewer audit risks for hospitals than inpatient. Hospitals can be financially penalized for inpatient admissions that auditors later say should have been observation. So hospitals often default to observation when the case is borderline, even when the patient ends up staying multiple nights.

What you can do during the stay

If you have already crossed two midnights and are still in observation status, ask the attending physician: "Given that I have been here more than two midnights, should I be converted to inpatient?" The physician can convert status at any time during the stay.

Documentation matters

For converting from observation to inpatient, the physician documents the medical justification. The conversion changes how the entire stay is billed and counted toward SNF eligibility.

Status - MOON notice

I got a paper called MOON

The Medicare Outpatient Observation Notice. Federal law requires hospitals to give it to any Medicare beneficiary placed in observation status for more than 24 hours. It tells you what observation status means and what the financial implications are.

Required by federal law (the NOTICE Act of 2015)

Hospitals must provide a written MOON within 36 hours of placing you in observation status, or before discharge if discharge happens sooner. The hospital staff must orally explain the notice and have you sign acknowledgment of receipt.

What the MOON tells you

That you are in observation status (not inpatient). That this means you are technically an outpatient. That you may have different cost-sharing than an inpatient. That observation days do not count toward the 3-day SNF qualifying stay.

Why it matters

The MOON is your formal warning. Once you have received and signed it, you cannot later say you did not know about observation status. It is also documentation if you need to appeal coverage decisions.

What to do when you receive it

Read it before signing. Ask questions before signing. Ask: "Why am I in observation? When will the doctor consider converting to inpatient?" Save the copy.

You can refuse to sign acknowledgment

You cannot refuse the status itself by refusing to sign, but you can refuse to acknowledge receipt. Some patients write "received but disagree with status" before signing. The hospital documents that you received the notice regardless.

Photograph the MOON with your phone

Take a photo of every notice you receive. Note the date and time. If you later need to appeal a coverage decision, the notices are evidence. Hospital records can be slow or hard to access; your phone photo is immediate.

Status - 3-day rule

The 3-day rule

Why the number 3 matters more than any other number in hospital care. Three consecutive inpatient days are required for Medicare to cover skilled nursing facility (SNF) care afterward. This rule determines tens of thousands of dollars of out-of-pocket cost difference for many families.

What counts as a qualifying inpatient day

Each midnight you spend in the hospital as a formal inpatient counts as a day. The day of discharge does not count. So you must be admitted before three midnights pass while you are still inpatient.

What does NOT count

Time in the ER before admission. Days in observation status. The day of discharge. Time in another hospital before transfer (some exceptions). All of these can extend your stay without counting toward the 3-day requirement.

The 30-day window

After your qualifying 3-day inpatient stay, you have 30 days to start the SNF stay for Medicare to cover it. If you go home for 31 days and then need SNF, the prior hospitalization no longer qualifies you.

What Medicare covers when the rule is met

Days 1-20 in the SNF: covered in full. Days 21-100: $217/day coinsurance (in 2026), the rest covered. Day 101+: not covered.

What happens when the rule is NOT met

You pay 100% of the SNF cost. SNF rates are typically $300-400/day depending on the facility and level of care. A 30-day SNF stay you expected to cost a few thousand dollars in coinsurance can cost over $10,000 if the 3-day rule was not met.

Some Medicare Advantage plans waive the rule

Some MA plans, especially newer value-based ones, do not require the 3-day stay. If you are in MA, ask your plan whether they waive the requirement. This is one situation where MA can offer a benefit Original Medicare does not.

Confirm your status before discharge

Many SNF coverage problems are discovered after discharge when families realize the hospital stay did not include 3 inpatient days. Confirm your status repeatedly during the stay. Ask for written confirmation. The cost difference is enormous.

Status - What this costs

What does this cost

For Original Medicare patients admitted as inpatient, hospital costs are predictable but not small. Knowing the structure helps you budget and recognize bills that look wrong.

Part A deductible (2026): $1,736

You pay this once per benefit period, not per year. A benefit period starts the day you are admitted as inpatient and ends when you have been out of the hospital or SNF for 60 consecutive days. If you have two hospitalizations 90 days apart, that is two benefit periods and two deductibles.

Days 1-60: $0 daily coinsurance

After meeting the Part A deductible, you pay nothing per day for the first 60 days of an inpatient stay. Most hospital stays end well before day 60.

Days 61-90: $434/day (2026)

For unusually long stays, days 61 through 90 carry this daily coinsurance. Few patients reach this.

Days 91+: lifetime reserve days at $868/day

Each Medicare beneficiary has 60 lifetime reserve days that can be used for stays beyond 90 days. Once used, they are gone forever.

After lifetime reserve days are exhausted

You pay 100% of hospital costs. Almost no one reaches this in practice.

Medicare Supplement (Medigap)

If you have a Medigap plan, it typically covers the Part A deductible and most or all of the daily coinsurance for the entire inpatient stay. This is one of the most valuable Medigap benefits.

Medicare Advantage

MA plans have their own cost-sharing for hospital stays, often a per-day copay for the first several days. Check your plan summary or call your plan to understand specifics. MA out-of-pocket maximum (max $9,250 in 2026) caps annual exposure.

Status - Appealing observation

Can I appeal observation status

Direct appeal of observation status during a hospital stay is limited. But there are paths to challenge the determination, and after-the-fact appeals exist when observation status caused real harm.

No direct appeal during the stay

Unlike a discharge, observation status itself cannot be appealed in real time through the QIO. The status is set by the admitting physician based on clinical and regulatory factors.

Ask the physician to reconvert

The clearest path is to ask the attending physician or hospitalist to reconsider observation status and convert to inpatient. They have authority to do this if clinical circumstances support it.

Request administrative review

Some hospitals have utilization management physicians who review status determinations. Ask the case manager: "Can the utilization review physician reconsider my status?"

Document everything

If you believe observation status is wrong, write down: when you arrived, your symptoms, your diagnosis, the treatment received, the duration of your stay. This documentation matters if you later need to challenge.

After-the-fact appeals

If observation status caused you to lose SNF coverage and you incurred costs, you can appeal through the Medicare appeals process. The first level (redetermination) goes to the Medicare Administrative Contractor. Higher levels exist if denied.

Class action precedent (Alexander v. Azar)

Federal court decisions have established that Medicare beneficiaries have a right to appeal status reclassifications from inpatient to observation. The implementation of these rights continues to evolve. Patient advocacy organizations track this.

Get help appealing status

Information on Medicare appeals.

Center for Medicare Advocacy

medicareadvocacy.org

Free legal help for observation status appeals.

Stay - Medications

Why are they giving me different medications

Hospital pharmacies do not stock every medication on the market. They use formularies that prioritize cost, availability, and standardized protocols. Most substitutions are clinically fine. Some are not. Knowing which is which prevents problems.

Generic substitution is the most common change

Brand-name medications are almost always substituted with generic equivalents. For most medications, this is clinically equivalent. The active ingredient is identical; the inactive ingredients (binders, fillers, dyes) may differ.

Same generic, different manufacturer

Generic medications come from many manufacturers and the inactive ingredients vary. A patient who has been stable on one generic for years may notice differences when switched to another. This is more common than people realize.

Some medications have narrow therapeutic windows

Levothyroxine (thyroid), warfarin (blood thinner), digoxin (heart), levetiracetam and other seizure medications, and certain immunosuppressants are sensitive to manufacturer differences. Tell the pharmacy if you have specific brand requirements.

Hospital protocols sometimes substitute drug classes

A patient who takes lisinopril at home may be switched to a hospital-preferred ACE inhibitor. A patient on a specific PPI may be switched to another. Tell the team if you have had problems with the drug class you are being switched to.

IV vs oral routes

Many medications are given IV in the hospital that you take orally at home. Sometimes this is necessary; sometimes it is default and oral would work. Ask if oral is acceptable. Oral is more comfortable and easier to continue at discharge.

What to push back on

A clear past adverse reaction to a medication. A specific brand or formulation that has worked when others have not. A medication you cannot afford after discharge if you start it in the hospital.

Stay - Rapid response

Something is changing. Get more help

When a hospitalized patient is deteriorating, time matters. Most hospitals have rapid response teams (RRTs) for early intervention before a full crisis. Many hospitals now allow family members to activate the RRT directly. Knowing how to use this system saves lives.

Tell the nurse first

Any concerning change should go to the nurse first. They evaluate and decide whether to escalate. Most concerns are handled at this level - vital signs, pain, breathing changes, anxiety. Be specific about what is different from before.

Rapid Response Team (RRT)

Most hospitals have a rapid response team available 24/7. Staffed by ICU-level nurses and physicians, they evaluate within minutes when called. The threshold for activation is "patient may be deteriorating" - not "patient is coding."

Family-activated rapid response

Federal Joint Commission guidance and many state laws now require hospitals to allow family activation of rapid response teams. Different hospitals call this Condition H, Condition Help, or just Family RRT. Ask: "How does the family activate rapid response here?"

When to activate

Sudden change in mental status. New shortness of breath. New severe pain. Cold or pale skin. Decreased responsiveness. Family sense that something is wrong even without specific symptoms. The threshold is appropriately low.

What happens when called

A team arrives at the bedside in 2-5 minutes. They evaluate, may order tests or treatment, and may decide to transfer to a higher level of care (stepdown unit or ICU). They communicate with the primary team afterward.

Code Blue is different

A "Code Blue" is called for cardiac arrest or respiratory arrest - the patient has stopped breathing or has no pulse. Different team, different protocol, much more urgent. Rapid response is for early deterioration, before the crisis.

Family-noticed deterioration is a real clinical signal

Studies of hospital deaths show that family members who feel something is wrong are often correct. They know the patient's baseline. "He is just not himself" is a valid clinical observation. Push back if dismissed.

Stay - ICU transfer

Should I be in the ICU

Most hospital stays do not need ICU care. Some clearly do. The hard decisions are in the middle - patients who could go either way. If you believe your loved one needs ICU care and they are not there, you can ask.

What ICU offers that the regular floor does not

Continuous monitoring (heart rhythm, blood pressure, oxygen). 1:1 or 1:2 nurse-to-patient ratio (vs 1:5 on the floor). Bedside availability of physicians. Equipment and protocols for rapid intervention. Very different staffing model.

Stepdown or telemetry units

Between the regular floor and ICU. Higher monitoring than the floor (continuous heart rhythm and oxygen, more frequent vital signs). Better staffing than the floor (1:3 or 1:4). For patients who need close watching but not full ICU.

Who decides on ICU transfer

The attending physician or hospitalist makes the call, sometimes after consultation with intensive care or pulmonary critical care. The ICU team typically has authority to accept or decline.

Reasons to ask for ICU evaluation

Worsening vital signs (heart rate, blood pressure, oxygen). New confusion or decreased responsiveness. Increasing oxygen requirement. Inability to tolerate medications by mouth when they are needed. Signs of organ dysfunction.

Phrases that work

"I am worried they need a higher level of care. Can the ICU team evaluate?" "Their condition seems to be changing faster than the floor can keep up. Should we be in stepdown?" Specific concerns expressed clearly trigger formal evaluation.

What if the answer is no

If the team evaluates and decides ICU is not appropriate, ask why. Document the conversation. Continue monitoring. If you continue to be concerned, activate rapid response or ask for a re-evaluation.

Stay - Hospital infections

Hospital-acquired infections

Hospital-acquired infections (HAIs) are infections you did not have on admission but contract during your stay. They are a real risk, especially for older or sicker patients, but most are preventable. Knowing what to watch for and what hospitals are required to do helps you advocate.

Common types

Catheter-associated urinary tract infections (CAUTIs). Central line-associated bloodstream infections (CLABSIs). Surgical site infections. Ventilator-associated pneumonia. C. difficile colitis (severe diarrhea, often after antibiotic use). MRSA infections.

Hand hygiene is the single most important prevention

Hospital staff should wash hands or use sanitizer entering and leaving every room, before and after every patient contact. You can ask, politely: "Did you wash your hands?" Most staff appreciate the reminder.

Catheter and line management

Urinary catheters and IV lines should be removed as soon as they are no longer medically necessary. Each day a catheter or line stays in is another day of infection risk. Ask: "Does this catheter still need to be in? Can it come out?"

Isolation precautions

Some patients are placed on contact, droplet, or airborne isolation. Staff wear protective equipment. Visitors may need to as well. This is to prevent spread of resistant organisms or infectious diseases.

Federal reporting

Hospitals are required to report HAI rates to CMS. Rates are publicly available at medicare.gov/care-compare. If you are choosing between hospitals (when you have the time), HAI rates are one factor.

Recognizing infection early

Fever. Increased pain or redness at any incision or line site. New cough or shortness of breath. New diarrhea (especially watery and frequent). Confusion in older patients. Tell the nurse immediately if any of these develop.

Stay - Falls

Falls in the hospital

Hospital falls are common and often serious. Most are preventable. Hospitals have specific protocols for fall prevention. Patients and families can help by knowing what those protocols are and what to expect.

Why falls happen in the hospital

Patients are deconditioned, sedated, on new medications, in unfamiliar environments, attached to lines and tubes, with bathroom needs and mobility limitations. Most falls happen during attempts to get to the bathroom unassisted.

Fall risk assessment

Hospitals assess every patient for fall risk on admission and reassess at least daily. High-risk patients are flagged in the chart, often with a colored band or sign. The fall risk score determines what precautions are used.

Bed alarms and chair alarms

Pressure-sensing pads under the patient that trigger an alarm when they get up. Used for high-risk patients. The patient may experience these as restrictive but they significantly reduce falls.

Mobility orders

The team specifies how much you should move - bedrest, bedrest with bathroom privileges, ambulation with assistance, ambulation as tolerated. Following the mobility order matters; doing too much is a major fall risk, doing too little leads to deconditioning.

Asking for assistance

Use the call button before getting up. Wait for help. This is the single most important thing patients can do to prevent falls. Many patients do not want to bother the nurse, then fall trying to get to the bathroom alone.

What to do after a fall

Do not move the patient. Tell the nurse immediately. The team will assess for injury, often with X-rays. The fall is documented. Risk factors are reassessed. Many post-fall injuries are not immediately obvious - hip fractures, head injuries, internal bleeding can develop or worsen over hours.

Bring a family member overnight if possible

For high-risk patients, having a family member sleep in the room dramatically reduces fall risk. The family member helps with bathroom trips and notices changes during the night when nurse coverage is thinner.

Stay - Getting worse

I am getting worse, not better

Most hospital stays show daily improvement. When that does not happen, it can mean the diagnosis is wrong, the treatment is not working, or a complication has developed. Recognizing this and escalating appropriately changes outcomes.

Track daily progress

Each morning, ask: "Am I better, the same, or worse than yesterday?" Track this in writing. The team is busy; you have one job, which is to notice changes in yourself or your loved one.

Three days without improvement is significant

For most acute conditions, you should see meaningful improvement within 2-3 days of starting treatment. If you are no better after 72 hours, ask the team: "Why am I not improving? Is the diagnosis correct? Should we be considering alternatives?"

Ask about second opinions while inpatient

You can request a specialist consultation even mid-admission. "I would like a [cardiology/pulmonology/infectious disease] consult to weigh in." Specialists can review the case fresh and may suggest different approaches.

Asking for a higher level of care

If your condition is worsening on the regular floor, ask about transfer to stepdown or ICU. The threshold should not be "I am about to crash" but "I am not getting better and need closer monitoring."

Reconsidering the diagnosis

When patients are not improving, the working diagnosis may be wrong. Asking "What else could this be?" sometimes prompts the team to reconsider. Differential diagnoses get closed off too early in some cases.

Family meetings

For complex worsening situations, a formal family meeting with the hospitalist and any involved specialists is appropriate. This focuses everyone, surfaces disagreements, and produces clearer decisions.

Escalate concerns

Ask the nurse

First line of escalation. Be specific about what is not improving.

Family-activated rapid response

Ask your hospital

Available at most US hospitals for deteriorating patients.

Rights - IM notice

I got this paper at admission

The Important Message from Medicare (the IM). Required by federal regulation. Given to every Medicare beneficiary at admission and again before discharge. The IM is the basis for your right to appeal a discharge.

Required by federal regulation

42 CFR 405.1205. Hospitals must provide the IM at admission and again 4-48 hours before the planned discharge. The hospital must explain it orally and have you sign acknowledgment of receipt.

What the IM tells you

That you have the right to receive Medicare-covered services. That you have the right to appeal a discharge decision. The phone number for your state Quality Improvement Organization (QIO), the body that hears discharge appeals.

Why the IM matters

You cannot appeal a discharge unless you received an IM. The IM gives you the QIO contact information, which is the only path to file the appeal. Save your copy.

When you receive the second IM

Before the planned discharge - typically 4-48 hours before. This is your formal notice that discharge is imminent and that you can appeal if you disagree.

What to do if you disagree with discharge

Read the IM. Call the QIO number on the IM before noon of the day after the planned discharge. Tell the discharge planner you are appealing. Document the call.

Save the IM

Photograph it with your phone. Note the date and time you received each one. The IM is evidence if you need to demonstrate that you appealed in time.

Rights - HIPAA

Doctors won't talk to my family

HIPAA (the Health Insurance Portability and Accountability Act) governs who can see and discuss your medical information. In the hospital, this often becomes a barrier to family communication. Knowing how it works prevents most problems.

Sign HIPAA authorization at admission

Specify which family members can discuss your care. Most hospitals have a form. Update at every admission and whenever family situations change. Without authorization, even your spouse can be excluded by strict interpretation.

What family members can do without authorization

Be present in the room (you can authorize this). Be present during medical conversations (you can authorize this). Receive information from you (you control this). What they cannot do without HIPAA authorization is independently call and get information when you are not present.

In emergencies, providers can share information

When a patient is incapacitated and a healthcare decision must be made, providers can share information with family if doing so is in the patient's best interest. But many providers default to the strictest interpretation, so explicit authorization is safer.

Patient portal access via HIPAA proxy

Most major hospital systems allow patients to designate proxy access to the patient portal. The proxy can see lab results, imaging reports, and visit notes. Set this up early - portal access is one of the most useful tools families have.

What to do when blocked

Tell the nurse: "I want to update my HIPAA authorization to include [family member name]." Most floors can produce a form within minutes. If staff cannot find one, ask the case manager or charge nurse.

Filing a HIPAA complaint

If you believe your HIPAA rights were violated (information shared without authorization, or access to your own records denied), file a complaint with the HHS Office for Civil Rights. Free, no lawyer needed.

Set up family communication

Ask the nurse for a HIPAA form

Update authorization at every admission.

HHS Office for Civil Rights

1-800-368-1019

For HIPAA complaints if rights are violated.

Rights - Refusing treatment

I want to refuse a treatment

A competent adult has the right to refuse any medical treatment, including life-sustaining treatment, even mid-admission. This right applies to surgery, medications, IV fluids, blood transfusions, ventilators, feeding tubes, and dialysis. The right is settled federal law.

You can refuse any treatment, at any time

Even treatment you previously consented to. Even treatment that is in progress. Even life-sustaining treatment. The right is grounded in constitutional bodily autonomy.

Decision-making capacity is required

You must understand the situation, the options, the consequences, and be able to communicate a choice. Disagreeing with the doctor does not mean you lack capacity. Many physicians confuse the two.

How to refuse

Tell the team clearly: "I do not consent to this treatment." Get it in writing if possible. Sign a refusal form if offered, or write your refusal on a chart note. The hospital will document.

AMA discharge

Against Medical Advice. You can leave the hospital even if doctors recommend staying. There can be financial implications (some insurance issues if leaving against advice contributed to a bad outcome) but the right to leave is yours.

Refusing specific things

You can refuse a specific medication while accepting others. You can refuse a specific test while accepting treatment. You can refuse a specific intervention (intubation, CPR, dialysis) without refusing care entirely. Be specific.

In emergencies when you cannot communicate

If you cannot communicate, providers act on the assumption that you would want life-saving treatment unless they have a clear advance directive or POLST saying otherwise. This is why advance directives matter.

Refusing care is your right but consequences are real

Refusing recommended treatment can result in worse outcomes. The right to refuse is yours; the consequences are also yours. Make refusal decisions with full understanding of what you are accepting in return.

Rights - Refusing destination

I refuse where they want to send me

You cannot be forced to go to a specific skilled nursing facility, rehab, or other post-acute destination. The hospital must give you a list of certified facilities and you choose. If none of the choices feel acceptable, you have alternatives.

You choose your post-acute destination

The hospital must give you a list of Medicare-certified SNFs in your area. You choose. The hospital can suggest, but you decide. This is established federal regulation (42 CFR 482.43).

You can refuse a specific facility

If a SNF has poor reviews, low ratings on medicare.gov/care-compare, complaints, or a quality of care concern, you can refuse it. Ask for the next option on the list.

You can refuse SNF entirely

If you would rather go home with home health than to a SNF, you can. The case manager will work with you to make a home discharge work, including arranging home health, equipment, and family support.

You can refuse rehab

Inpatient rehabilitation requires the patient to actively participate in 3+ hours of therapy daily. If you do not believe you can or want to participate at that intensity, you can decline rehab.

Alternatives if you refuse what they propose

Home with home health (Medicare covers home health if you are homebound and need skilled care). Outpatient therapy (you live at home and go to therapy several times per week). Hospice (if appropriate). Family caregiving with no formal services.

What if the team says you cannot go home

They can recommend, but they cannot force. They may document that the discharge is against their recommendation. You can still go home. If they refuse to discharge you home, you can leave AMA.

Rights - Advance directives

Do I need an advance directive

Advance directives are legal documents specifying your wishes for medical care if you cannot make decisions yourself. They matter most in emergency situations or when you have lost decision-making capacity. The hospital is a good place to create one if you do not have one.

Three main types

Living will (states wishes for life-sustaining treatment in specific situations). Healthcare power of attorney (names a person to make decisions when you cannot). POLST or MOLST (a medical order signed by a doctor that translates wishes into actionable orders for emergency responders).

Do you need one for an admission

Not legally required. But you should be asked at admission whether you have one. If you do, bring a copy and ask for it to be added to your chart. If you do not, the hospital social worker can usually help you create one.

Free state-specific forms

caringinfo.org has free advance directive forms specific to every state. Five Wishes (fivewishes.org) is a user-friendly format that meets legal requirements in most states. Some states require notarization or witnesses.

Healthcare proxy is the most flexible

A named healthcare proxy can adapt to circumstances you did not anticipate. They make decisions based on what you would want, not what is written on a form. Choose carefully - someone who knows your values and can speak under pressure.

Living wills can be too generic or too specific

Generic ("no extraordinary measures") leaves too much to interpretation. Too specific leaves gaps the situation does not match. Best is generic principles plus specific guidance about scenarios you care about.

Where to keep them

Multiple copies. With your healthcare proxy. With your primary care doctor. In your medical record at your hospital system. In your home where family can find them. Do not keep the only copy in a safety deposit box.

Create advance directives

Free state forms

caringinfo.org

Free state-specific advance directive forms from NHPCO.

Five Wishes

fivewishes.org

User-friendly advance directive that meets legal requirements in most states.

POLST national

polst.org

Find your state POLST or MOLST form.

Rights - Surrogate decisions

What if I cannot decide

When a hospitalized patient cannot make decisions, someone else must. Knowing who that is, what authority they have, and how decisions should be made prevents conflict and ensures the patient's wishes are followed.

First, the named healthcare proxy

If the patient has a healthcare power of attorney or advance directive naming someone, that person becomes the decision-maker. Their authority is broad - any medical decision the patient would have been able to make.

Default surrogate by state law

If no healthcare proxy was named, every state has a default surrogate hierarchy. Typical order: spouse, adult children (often together), parents, siblings. State laws vary. Knowing your state rules matters because conflicts happen.

Substituted judgment standard

Surrogates decide based on what the patient would want, not what the surrogate wants. This is "substituted judgment." If the patient said clearly what they wanted, follow it even if you disagree. If you do not know, decide based on what they would likely want given their values.

Best interests standard

When the patient never expressed wishes, surrogates decide based on the patient's "best interests." This is more subjective. It usually means: minimize suffering, maximize quality of life, respect dignity.

Conflict between surrogates

When multiple family members have surrogate authority and disagree, hospitals follow conflict resolution policies. This often means an ethics committee consultation. Major decisions (withdrawal of life support, DNR orders) often require unanimous agreement.

Limits of surrogate authority

Surrogates cannot consent to: experimental treatments outside FDA-approved protocols, sterilization, psychiatric commitment in some states, or actions clearly against the patient's known wishes. Surrogates cannot override an advance directive unless the directive is silent on the specific issue.

Discharge - Early planning

When does discharge planning start

Discharge planning starts on day one of admission, whether the patient knows it or not. The case manager begins evaluating discharge needs immediately. Patients and families who engage early shape the plan; those who wait until the day before discharge get whatever the case manager arranged.

Federal law requires discharge planning

42 CFR 482.43 (the CMS Conditions of Participation for hospitals) requires every Medicare-certified hospital to have a discharge planning process. Every patient must have a discharge plan that addresses post-hospital needs.

Case managers begin within 24 hours

In most hospitals, case managers screen new admissions for discharge planning needs within 24 hours. They identify whether you will need home health, equipment, SNF, rehab, hospice, or just a follow-up appointment.

You have a right to participate

Federal regulation requires hospitals to involve the patient and patient's representative in discharge planning. You can request a meeting with the case manager at any point. You should be informed about the proposed plan before it is finalized.

What gets decided early

Whether you go home or to a facility. Which type of facility (SNF, rehab, LTAC). Which specific facility within that type. What home equipment will be ordered. What home health services. The follow-up doctor and timeline.

What changes if you wait

By the day before discharge, decisions are mostly made. The SNF placement is arranged. The equipment is ordered. Changing course at that point is possible but harder. Some options may no longer be available.

Asking for the meeting

Tell the nurse: "I want to meet with the case manager today to discuss discharge planning." This usually triggers a meeting within 24 hours. Some hospitals have dedicated discharge planning rounds where you can be present.

Discharge - Where to go

Where can I go after the hospital

Six main destinations after a hospital stay. Each has different eligibility, coverage, and clinical fit. Choosing the right one depends on your medical needs, functional level, and personal situation.

Home with no services

You go home and resume normal life with whatever family support you have. Best for healthy patients with minor illnesses. Coverage: just transportation home, which is your responsibility.

Home with home health

You go home and a home health agency sends nurses and therapists for visits. Best for patients who are homebound, need intermittent skilled care, but do not need 24-hour facility care. Medicare Part A or B covers if eligibility criteria are met.

Skilled nursing facility (SNF)

You go to a facility for short-term skilled care, typically 7-30 days. Best for patients who need daily skilled nursing or therapy but not hospital-level care. Medicare Part A covers if you had 3 inpatient days. $217/day coinsurance days 21-100 in 2026.

Inpatient rehab facility (IRF)

A specialized rehab hospital. You participate in 3+ hours of therapy daily. Best for patients with stroke, spinal cord injury, brain injury, complex orthopedic surgery, who can tolerate intensive therapy. Medicare Part A covers under different rules than SNF.

Long-term acute care (LTAC)

A hospital-level facility for medically complex patients with extended needs (typically ventilator weaning, complex wounds, severe infections). Average stay 25+ days. Medicare Part A covers.

Hospice

Comfort-focused care for patients with prognosis of 6 months or less. Can be at home, in a hospice facility, or in a nursing home. Medicare hospice benefit (Part A) covers all hospice services.

Discharge - SNF vs rehab

SNF or inpatient rehab

Two different post-acute programs that families often confuse. SNF and inpatient rehabilitation facility (IRF) have different intensity, different eligibility, different coverage rules, and serve different patients. Choosing correctly matters.

Skilled nursing facility (SNF)

Lower-intensity rehab combined with nursing care. Therapy 1-2 hours per day if tolerated. Patients often have multiple conditions and lower functional baseline. Average stay 14-30 days.

Inpatient rehabilitation facility (IRF)

High-intensity rehab. 3+ hours of therapy 5+ days per week. Patients must be able to actively participate. Average stay 10-21 days. More like a specialized hospital than a nursing home.

Eligibility for SNF

Must have had 3 consecutive inpatient hospital days. Need daily skilled nursing or therapy. SNF must accept Medicare. Stay must begin within 30 days of hospital discharge in most cases.

Eligibility for IRF

No 3-day prior hospitalization rule. Must require active intensive therapy. Must have a condition that benefits from intensive rehab (typically stroke, brain or spinal cord injury, complex orthopedic surgery, certain neurological conditions, severe burns). Must be medically able to tolerate the intensity.

Coverage for SNF

Medicare Part A covers. Days 1-20 fully covered. Days 21-100 carry $217/day coinsurance (2026). Day 101+ not covered.

Coverage for IRF

Medicare Part A covers under acute care benefits. Same Part A deductible structure as a hospital admission. Better coverage than SNF for the same stay length.

How to choose

For most older patients with multiple conditions, SNF is the right choice. For patients with focused recovery needs and good baseline function (stroke survivor, post-orthopedic surgery, etc.), IRF is often better. The hospital team will recommend based on clinical fit.

Discharge - Appealing

I am not ready to leave

You have the right to appeal a hospital discharge decision through your state Quality Improvement Organization (QIO). The deadline is short, the process is fast, and using it correctly often gets you another day or two of inpatient coverage.

1
Tell the hospital you want to appeal
As soon as you receive the IM (Important Message from Medicare) saying you will be discharged, and you do not believe you are ready, tell the discharge planner or nurse: "I want to appeal this discharge." Get this in writing if possible. Note the time.
2
Call the QIO immediately
The IM has the QIO phone number for your state. Call as soon as possible, ideally before noon on the day before the planned discharge. The QIO must receive your appeal request before noon of the day after you receive the IM.
3
Stay in the hospital while reviewed
Once you file the appeal, you cannot be charged for hospital care while the QIO reviews. The QIO must respond within 1 day of receiving all medical records. So you typically buy 1-2 extra days.
4
If the QIO upholds the discharge
You will be discharged. You can still file higher-level appeals but they will not delay discharge. Document everything. If the QIO finds the discharge was inappropriate, you have grounds for refund of any costs incurred.
5
If the QIO sides with you
The hospital must continue covering your stay. The case manager will work with you on a more appropriate discharge plan, possibly with home health, family training, or a different post-acute placement.

File a discharge appeal

Find your state QIO

qioprogram.org

Each state has a QIO. The IM you received has its phone number.