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“Drop a lil' knowledge on 'em”

Medication Reconciliation (Discharge)

  • Navigate to the Med Rec as seen in “How to Admit a Patient”
  • With your Senior, complete the Med Rec for discharge
    • This is the main opportunity to stop or change medications for the patient after discharge
      • Once this step is completed, you will see the "check" beside Home Medications as below.

Green Check

Patient Instructions/Follow-Ups/Education

  • Navigate to the Inpatient Workflow Discharge Platinum and select the “Patient Instructions”

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  • The instructions can be done multiple ways and as long as you communicate to the patient what needs to be done, you can do this as you like. I utilize the Uptodate method to break it down into simple easy to digest steps. I then saved it as a dotphrase .jsdischargeinstructions
    • Just make sure to save this field as it will autopopulate into your Discharge summary
    • Anywhere within the Instructions field, press Ctrl + A, then Ctrl + C

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  • Make sure to complete the Follow-ups and Patient education on the same page as you go

    • Follow-ups are typically with the patient’s PCP, generally I have them follow up within a few days to 10 days depending on the condition.
      • Option 1) Patient’s PCP is a random person somewhere else
        • It is not required, but encouraged to notify them about their patient needing a follow up
      • Option 2) Patient is established with Dr. Aman, Dr. Hadley, Dr. John, Dr. Durden, or Dr. Griffith
        • You will need to Select “Communicate and Message” at the top of the page to create a new message for their clinic
      • To do so:

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    • Send this message
      • Option 3) Patient is OPCC Resident’s patient
        • Same process as above but will select “MEM Outpatient Care Center – TCM” as the message recipient
      • NOTE: Do not schedule TCM visits if the patient is going to a SNF
    • Patient Education is to be selected based on relevance to their condition
      • Ex. Pt admitted for AECOPD could be given information on signs and symptoms of COPD exacerbation or the ALA’s information on grading their COPD exacerbation severity

Discharge Instructions

  • Prior to generating the Discharge Instructions, make sure the Home Medications, Follow-Up, and Patient Education tabs have the green check mark beside them in the Inpatient Discharge MPage. The Order Profile should still have the red star.
  • Now it is time to create the patient’s discharge instructions

    • Type: Discharge Instructions
    • Note Template: Free Text Note
    • Title: “CAMC IM Discharge Instructions”

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  • Now, at the bottom there will be my generic instructions, delete those and press Ctrl + P

  • This should paste the modified instructions from your instructions tab you completed in the previous step.
  • Sign and Print this page. You will give this to the patient.

Discharge Summary

  • “Discharge summaries are to be done within 36 hours of discharge or prior to transferring a patient to another facility”
  • A discharge summary can replace a progress note for the day
    • Ex. Discharge Mr. Hill at 2pm and complete discharge summary = no need for progress note that day
  • Type: Discharge Summary
  • Note Template: Inpatient Discharge Summary
  • Title: “CAMC IM Discharge Summary”
    1. Dates of Service/Admitting Diagnosis/Primary + Secondary Discharge Diagnosis
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    2. Procedures/Consults
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    3. Studies
      • Use the .jsimaging_report dot phrase
        • Note: ECHOs/Vascular Studies are not added in this dotphrase and must be added manually.
        • Try to delete extraneous information if possible
          • Ex.

            1. CTA w/o Contrast
            2. MM/DD/YYYY 12:00:00
            3. IMPRESSION: Bad study
            4. Electronically Signed by: Reading Physician

    4. Hospital Course
      • Within the hospital course field on your Inpatient Workflow Discharge Platinum or within your inpatient workflow, you can complete the hospital course to auto populate into your discharge summary
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    5. Physical Exam/ Follow-Up Appointments/ Follow-Up Labs/Studies
    6. Discharge Medications/ Pending Labs and Studies/ Condition on Discharge
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    7. Patient Instructions/Discharge Disposition/Physician Orders/Signature
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