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Online Discharge Summary Tutorial Create Online Discharge Summaries & Addendums Table of Contents Start • From POE • From the Portal • After Signing the Discharge Order Enter & Edit • Access Clinical Data • Enter Data Print • In Progress Documents • Completed Documents Complete 1 Start a Summary or Addendum There Are Three Ways To Start: 1) From the POE Main Menu 2) From the Portal For Discharge Summaries Only: 3) Directly After Signing the Discharge Order From the POE Main Menu 1) Select patient from the POE Dashboard (inpatients only) or via the Other Patient link at the top of the dashboard 2) Click the Discharge Summary link on the POE Main Menu 2 From the Portal 1) Click the CareWeb Link on the Left Side of the Portal 2) Select Discharge Summary 3) Enter CCC Key 4) Search For Patient By Floor, Name or MRN 3 After the Patient is Selected the Discharge Summary Information is Presented Click the Appropriate Link To: • Find the Patients For Whom You Have Started A Summary • Start A New Summary or Addendum • View & Print Documents • Edit In Progress Documents • Find a New Patient (if Accessing via the Portal) Or Exit 4 Directly After Signing the Discharge Order When you sign the discharge order in POE you must first select who is responsible for writing the Discharge Summary If the default name is not correct, type the full or last name of the responsible person into the textbox and click ‘Lookup’ You will be presented with the related names. Click the name of the person you want and then press OK 5 After selecting the responsible summary writer and reviewing the worksheet and medications, you have the option of proceeding directly into the discharge summary after signing the order Select this option and you will be presented with the sections of the Discharge Worksheet that will be automatically imported into the summary Click Save/Menu 6 Enter & Edit Discharge Summary Main Screen This is the main screen from which you can start, edit & complete a summary. There are three main sections: • • • Links to Edit Each Section of the Summary Patient Profile Information Ongoing Text of the Summary 7 7 6 Access Data The Online Discharge Summary presents you with data from the following sources to help you build your summary: • Team Census Notes • Discharge Worksheet • OMR Problem Lists • Notes – Past Discharge Summaries, Operative Notes, & all other OMR Notes • All Online Reports – Including Cardiology, Radiology, & Pathology • Results – Blood, Urine, CSF, Microbiology, etc. Click the appropriate button to review data and to copy and paste it directly into the body of the summary 8 Enter & Edit To Create the Summary, Enter Data and Text into the Corresponding Text Boxes Also Note: Discharge Worksheet Data Is Available For Appropriate Sections Click the Blue Link To Default the Information Into the Summary When Finished With Each Section, Click: Save/Continue to Proceed to the Next Section OR Save/Menu to Return to the Home Page 9 8 Print A Summary or Addendum In Progress Documents At any time a draft of the summary or addendum can be printed. Click the Print Draft button on the main screen Select the sections you want and click Print. If you would like to print all sections, just click Print. 10 Print A Summary or Addendum Finished Documents Select the ‘View/Print’ link from the Discharge Summary Information page. To print the summary, click Print 11 10 Complete A Summary • Complete: Sends Summary to Attending For Signature • STAT Complete: Sends to Attending & Prints Locally • Exit: Closes Application, Writer Can Return Later 12 11 Selecting Either Complete Option Takes You To This Screen: Select the Attending MD responsible for signing the summary (only available if more than one Attending was assigned to the patient during the current stay) Press OK If STAT Complete Was Selected, Pressing OK Will 13 Immediately Print the Summary At Your Local Printer