Transcript Discharge Summaries

Discharge Summaries
Discharge Summaries
 Discharge Summaries
– Can be challenging
 What happens during a hospital course is now more
complex and more detailed than in the past, with
more data generated in a shorter length of stay
Discharge Summaries
 Discharge Summaries
– Are a necessary patient safety device
– Serve as a vital piece of communication
between the inpatient team and the outpatient
primary care physician
Discharge Summaries
Discharge Report
Discharge Report
 All sections must be completed
– Please remember to select the correct Facility
on the pull down as this influences pharmacy
and other issues
– Continuing Patient Care (CPC)/Transfer Form Needed
 Click Yes If:
– Patient is going to a nursing home
– Patient is going to a rehabilitation facility
– Patient will be receiving any form of home care
Discharge Report
 View/Edit Manual Entry
– Capturing Key Elements of the Hospital Course
is critical for proper care following discharge
 Hospital Course
– Needs to be clear, concise, and organized
– Avoid nonstandard abbreviations
– Brevity is okay as long as all the appropriate
information is conveyed in an accurate manner
Discharge Summaries (suggested)
 Hospital Course
– Paragraph 1: Principal Diagnosis
– Paragraph 2: Secondary Diagnosis
– Paragraph 3: Brief History of Presenting Illness
with pertinent past medical history, family
history, and social history with
– Paragraph 4: Presenting Physical examination
with Pertinent labs, radiologic findings
– Closing List: numbered problem list with plan for
each problem and follow-up
CC List
• Please make sure PCP is selected, this will allow
discharge summary to be electronically sent to a HFMG
PCP when you submit the discharge
• Recommend cc any additional HFMG specialists who
saw the patient inpatient or will be following up as
outpatient
CC List
 Must Include
– Attending physician at time of discharge
– Name of intern or resident at time of discharge (if
applicable on a teaching service)
– Include PCP if within the Henry Ford Health System
– CC To:
 Other relevant physicians
 Anticoagulation Clinic
– Usually automatically selected if enrolled within Henry Ford
 Dialysis Unit
– Only West Pavilion or other Henry Ford Satellite Dialysis Units
Discharge Medications
Discharge Medications
Discharge Medications
 Always ask the patient what medications are needed at
discharge
– Do not refill and give all medications if they are not needed
 Patient wants medications from the discharge pharmacy
– Select Rx-Pharmacy-Lobby-HFH
 Send medications to the pharmacy
 Print and sign only controlled substance prescriptions
– Do not forget to include your DEA number
– Put on the front of the chart
– Discharge pharmacy will collect for their records
 Patient wants medication from outside pharmacy
– Call pharmacy to talk to the patient first
– Select Outside Pharmacy
 Print and sign the prescriptions and give to the patient
 Do not forget to put your DEA number on controlled substance
prescriptions
Diagnoses
Follow-up Appointments
Follow-up Appointments
 If scheduling follow-up with the patient’s
PCP specify the name of the PCP when
calling the discharge line
– Check the appointment to ensure the patient is
actually seeing his/her PCP
 Every patient does not need to be seen by
his/her PCP in one week
– The time interval for follow-up depends on the
patient diagnosis and what needs to be followed
in the outpatient setting
Submit
When ready to submit your document,
type your CarePlus password
and click “OK”
Submit
 Discharge summaries must be submitted
within 24 hours after discharge
Delete Discharge
 Rarely need to use this option
Vaccinations/Allergies
Patient Instruction
Patient Instruction
 Call Physician If:
– Please be sure to check the boxes that apply
 Patient Education Needs:
– Complete the sections as needed based on
each individual patient
 Patient Educational Material Given:
– It is imperative to check the appropriate boxes
(Heart Failure, Acute Myocardial Infarction,
Diabetes, Asthma) when applicable
Demographics
 Physicians do not enter any information in this section
Follow-up Care
Follow-up Care
 Follow-up care / Other instruction
– Include:
 Instructions for the home care nurse (what labs to
draw, when to draw next set of labs, who to notify
about lab results)
 Instructions for the nursing home/rehabilitation facility
regarding:
– What labs need to be drawn and when
– Anticoagulation if applicable
– Special diets and tube feedings if applicable
Home Health Care Services and Equipment
 Completed by the case manager
Case Manager
 Completed by the case manager