Discharge Instructions

Discharge Instructions
A Detailed How-To For Providers Last updated: 06/18/2014

Discharge instructions are document produced by the treatment team with the patient’s post-discharge plan of care. Social work/UM, providers, and nurses all contribute to the document. The discharge RN will print and give to patient prior to discharge. Last updated: 06/18/2014

Select the unit. Last updated: 06/18/2014

Select the patient. Last updated: 06/18/2014

Select Discharge Process.
Last updated: 06/18/2014

Select Discharge Instructions.

Select Add/Modify Instructions.

Pick ONE according to type of patient discharge.

You can review all the discharge instructions entered by the treatment team by clicking on the Summary tab. Last updated: 06/18/2014

Providers are mainly responsible for completing the following tabs / sections.

YELLOW tabs are REQUIRED for all patients

Social Services and Utilization Management complete these tabs / sections.

Nurses complete the NURSING tab.

Click on the General Tab.

Clicking the Clinic button will bring up a list of DPH and other primary care / specialty clinics. Select the desired clinic Last updated: 06/18/2014

Enter the clinic for patient’s follow-up visit(s) or free text if outside DPH system

Note: This will NOT schedule an appointment with the selected clinic.
Enter the already scheduled appointment date/time and provider. Note: This will NOT schedule an appointment with the selected clinic. Last updated: 06/18/2014

Select diet(s) and enter special dietary instructions if any
Select diet(s) and enter special dietary instructions if any. Instruct to quit smoking and void use of non-prescription drugs as applicable Last updated: 06/18/2014

Click on the Activity Tab.

Indicate if any restrictions regarding return to Work/School
Indicate if any restrictions regarding return to Work/School. Clicking any option in the Work / School section automatically generates a note for the patient when instructions printed by RN at the time of discharge. Last updated: 06/18/2014

Next, indicate what if any Activity Restrictions
Next, indicate what if any Activity Restrictions . If no restrictions mark “No Restrictions on Any Activity” box above. Last updated: 06/18/2014

Click on the Medical Tab.

Use simple language to explain to the patient in 1-2 sentences why he/she was admitted and treatments received. Last updated: 06/18/2014

Select all that apply for when to Notify Physician, Go to the ED, or Call 911.

Click on the Labs / Tests Tab.

Select or enter desired labs and indicate for when.

Choose indication from the drop down or free text with ICD code.
Click this box to search for ICD-9 codes. Choose indication from the drop down or free text with ICD code. NOTE: This serves as the actual order to the outpatient lab. ( If pediatric patient, please order through eCW.) Last updated: 06/18/2014

Document any additional tests already ordered for the patient.
NOTE: this is NOT an order. Order through usual processes Last updated: 06/18/2014

Click on the Wound Care Tab.

Complete any applicable fields
Complete any applicable fields. If this doesn’t apply, you can skip this tab. Last updated: 06/18/2014

Click on the Tubes / Drains Tab.

Complete any applicable fields
Complete any applicable fields. If this doesn’t apply, you can skip this tab. Last updated: 06/18/2014

Click on the Self Care Tab.

Only complete this section, if applicable.

Click the Save button located at the bottom of each section to save at any time. You may then continue working on the saved instructions or return at a later date. Last updated: 06/18/2014

To Finalize the document (all tabs completed as appropriate) so the nurse can print and hand it to the patient, click MD Finalize on the Summary tab. Last updated: 06/18/2014

Reminder The patient can’t be discharged until you hit the MD Finalize button. Don’t forget this important step, AFTER you’ve completed Med Rec and finalized ePDP. Last updated: 06/18/2014

Provider Discharge Documentation is complete!

You can view the instructions that will be given to the patient by selecting View Discharge Instructions. Last updated: 06/18/2014

Each line of the discharge instructions has a date, time, and author (CHN number). This shows who submitted each part of the final product. Last updated: 06/18/2014

Go back to Add/Modify Discharge Instructions to make changes to an already finalized document.

If you are revising a finalized discharge summary, click on the section you want to change then click “Modify” or go directly to the tab you want to modify. Last updated: 06/18/2014

When you are finished revising a previously finalized discharge instructions, click Revise MD Final as below. Last updated: 06/18/2014

After med reconciliation, discharge instructions, and ePDP complete, the RN who discharges the patient will print out the following documents: Last updated: 06/18/2014

Discharge Instructions

Return to Work / School Advisement

Discharge Medication List

Discharge RN’s signature
After discharge teaching is completed, the following signatures are obtained by RN: Discharge RN’s signature Patient / Family member’s signature Interpreter’s signature (if applicable). Last updated: 06/18/2014

Documents will ultimately be uploaded into the LCR Reports/Notes section.

Note: Printouts from the Discharge Pathway will take the place of discharge instruction forms.

Discharge Instructions

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Discharge Instructions

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