Within 48 to 72 hours of leaving the hospital, a follow-up call can help uncover problems with your medicines, appointments, and recovery. That is the window recommended in the Agency for Healthcare Research and Quality's Re-Engineered Discharge toolkit.[1]
Your doctor should help turn the hospital's instructions into a plan you can follow at home. You should know which medicines to take, who is checking unfinished test results, and when someone will reassess your recovery. Those are established discharge-care priorities across primary care models.[2]
Use the steps below to discuss responsibilities with your practice. Confirm its process before a planned hospitalization, or contact the office promptly after an unexpected stay.
Make Sure Your Doctor Has the Hospital Records
Tell the office which hospital treated you and when you left. Ask it to confirm that it received the records it needs.
Two documents serve different purposes. Discharge instructions explain what you should do at home. The discharge summary explains the hospital stay to the clinicians taking over your care. Your doctor needs the clinical context as well as your take-home instructions.[2]
The practice should review why you were admitted, what treatment you received, your condition at discharge, and the remaining follow-up tasks. If the summary is unfinished, the team may need to obtain information from the hospital chart or contact the clinicians who treated you.[1]
Send the paperwork you have through the practice's preferred secure channel. Keep your own copy and bring it to follow-up appointments, along with your medication list.[3]
A useful question for the office is: “Have you reviewed my discharge information, and is anything still missing?”
Reconcile Every Medication Change
Medication reconciliation means comparing medication lists, identifying discrepancies, and resolving them with the treating clinicians. Transitions into and out of the hospital are times when that comparison matters.[4]
Ask your doctor to compare what you took before admission, what the hospital prescribed at discharge, and what you are actually taking at home. The review should make clear which medicines continue, which changed, and which were stopped.[1][3]
The result should be one current list showing each medicine's name, strength, purpose, and instructions. Include nonprescription drugs, vitamins, supplements, and allergies. The Food and Drug Administration recommends updating this list whenever treatment changes and sharing it with clinicians and a trusted caregiver.[5]
Bring your bottles or clear photographs of their labels. Flag any difference between a bottle's instructions and your discharge paperwork. Ask the doctor or pharmacist to resolve it rather than choosing between conflicting directions yourself.[1][4]
Also say if a prescription costs too much, the pharmacy cannot fill it, or you cannot manage the instructions. The discharge team should help establish a workable way to obtain your medicines.[2]
Before the conversation ends, ask for the updated list in writing. You should be able to explain your schedule back in your own words and get clarification where needed.[1]
Give Every Pending Test a Named Follow-Up Clinician
Some hospital tests are still processing when you go home. An Agency for Healthcare Research and Quality-funded project found that clinicians disagreed about who was responsible for following pending inpatient results.[6]
Ask your concierge doctor to review the pending-test list and clarify responsibility with the hospital team. For each outstanding result, write down:
The test name.
The clinician responsible for reviewing it.
When the result is expected.
How you will receive the explanation and any next steps.[2]
The question to settle is whether your primary doctor, a specialist, or the hospital clinician will follow through. Ask for an explicit answer rather than assuming that everyone with access to the record is monitoring it.
You can also ask the practice to put a reminder in its system and tell you when to call if you have heard nothing. A result appearing in your portal is a reason to confirm the follow-up plan; it does not tell you whether the responsible clinician has acted on it.[6]
Turn Follow-Up Instructions Into Scheduled Care
Your discharge plan should identify the appointments you need, including dates, locations, and contact details. It should also address how you will get there.[2][7]
Ask your concierge practice to review the recommended timing and help resolve scheduling problems. Tell the office if the earliest available specialist appointment falls outside the hospital's requested window. The clinicians can then decide how to address the gap.
Keep the roles clear. Ask which issues your primary doctor will manage and which need the surgeon or specialist. Our guide to what happens when your concierge doctor refers you to a specialist explains the coordination questions to ask.
Timing should follow your individual discharge plan and clinical needs. The toolkit's early phone-call window is a framework for checking the transition, not permission to wait if you have an urgent problem.[1][8]
Check Whether the Plan Works at Home
Follow-up should include practical questions about eating, bathing, walking, obtaining prescriptions, and getting to appointments. Some patients also need equipment, wound-care supplies, or assistance from a caregiver.[3][7]
Tell the practice if an arranged service has not started or equipment has not arrived. Ask who will contact the discharge planner, home health agency, or supplier. Medicare's checklist also recommends discussing coverage and out-of-pocket costs with the appropriate staff or health plan.[3]
Include your caregiver in these conversations if you want their help. Ask for demonstrations when a task requires a skill, such as changing a dressing, and make sure the person doing it understands the instructions.[3]
Care coordination becomes visible in these details: someone checks what was arranged, identifies what is missing, and tells you who will address it.
Know Which Symptoms Need Immediate Attention
Your discharge instructions should explain expected recovery, warning signs, and whom to contact. Ask your doctor to clarify anything you do not understand, including the after-hours number.[3][7]
For a medical emergency, such as severe difficulty breathing, loss of consciousness, or bleeding that will not stop, call 911. Do not wait for a portal reply or a concierge callback.[8]
Keep emergency instructions where you and your caregiver can find them. A direct relationship with your doctor should come with a clear explanation of when emergency services are necessary.
A Checklist for Your First Follow-Up
Use these questions to review the transition with your practice:[1][2][3][5]
Have you received and reviewed my hospital records?
Do I have one updated medication list?
Are any test results outstanding, and who will review each one?
Are my follow-up appointments and any repeat tests arranged?
Have the home services and equipment I need arrived?
Do I know whom to call if recovery changes or an instruction is unclear?
If you are choosing a concierge doctor, ask the practice to walk through this process. Request specifics about who calls, who reviews records, and who follows up when another office has not responded.
FAQ
Should I wait for my concierge doctor to contact me?
Contact the office and confirm that it knows about your discharge. Ask when follow-up will happen, and follow the hospital's instructions in the meantime. Raise urgent concerns immediately.[1][7][8]
Does my doctor need to visit me in the hospital to help afterward?
Postdischarge review can use hospital records and communication with the inpatient team.[1] Ask separately whether your membership includes hospital visits and how the practice coordinates when it does not provide them.
Is this care only available through concierge medicine?
No. The discharge guidance cited here applies across care models.[2][3] When evaluating a membership, ask how the practice delivers these services, which are included in the fee, and which may generate separate charges.
What should I bring to the appointment?
Bring your discharge paperwork, medication list, questions, and any instructions from specialists. Share problems obtaining medicines, attending appointments, or managing care at home.[3][7]
Looking for a physician who can explain how they handle hospital follow-up? Find concierge and direct primary care doctors on NextMD, then ask each practice about its discharge-coordination process.
Sources
Agency for Healthcare Research and Quality. (2013). Tool 5: How To Conduct a Postdischarge Followup Phone Call. Re-Engineered Discharge Toolkit. Read the postdischarge follow-up guidance.
Agency for Healthcare Research and Quality. (2013). Tool 3: How To Deliver the Re-Engineered Discharge at Your Hospital. Re-Engineered Discharge Toolkit. Read the discharge-planning components.
Centers for Medicare & Medicaid Services. (2025). Your Discharge Planning Checklist. CMS Product No. 11376, December 2025, pp. 2–5. Download the patient and caregiver checklist.
Agency for Healthcare Research and Quality. (2024). Medication Reconciliation. PSNet. Read the medication-reconciliation primer.
U.S. Food and Drug Administration. (n.d.). Create and Keep a Medication List for Your Health. Accessed September 6, 2026. Read the FDA medication-list guidance.
Agency for Healthcare Research and Quality, Digital Healthcare Research. (n.d.). Improving Management of Test Results that Return After Hospital Discharge. Project profile. Read the pending-results research overview.
Brodkey, F. D., and A.D.A.M. editorial team. (2024). Leaving the Hospital: Your Discharge Plan. MedlinePlus Medical Encyclopedia, reviewed July 15, 2024. Read the hospital discharge guide.
Borke, J., and A.D.A.M. editorial team. (2025). Recognizing Medical Emergencies. MedlinePlus Medical Encyclopedia, reviewed January 8, 2025. Review emergency warning signs.