Gap Checking. What satisfies the components? From the Office of Clinical Informatics Cerner Millennium Nursing Discharge Process September 11, 2018
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- Everett Marshall
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1 Cerner Millennium The Discharge MPage in Nurse View replaces the Depart button on the Toolbar. Selecting discharge education, medication leaflets, documenting follow up appointments, documenting the Discharge Nursing Summary form, and printing the Patient Visit Summary will take place from the Discharge MPage. Nursing will complete the LACE tool in the Discharge Nursing form. Gap Checking Certain Discharge components have a red asterisk * beside them. If all the required documentation has been completed for the patient, a green checkmark will replace the red asterisk. The patient should not be discharged until all requirements have been met. Some of the requirements will need to be completed by the provider. Refer to the Electronic Clinical Quality Measures flyer for Quality Measures education. What satisfies the components? Orders to satisfy this requirement a Discharge Order needs to be placed by the provider. When a green checkmark displays, the nurse will know that a discharge order has been placed on this patient. IV Stop Times to satisfy this requirement, document IV stop times. Click Document Stop Times and select the infusion(s) to document stop times on. Infusion Billing opens for IV stop time documentation. Patient Education to satisfy this requirement, at least one education topic needs to be added. One of the suggested topics should be selected to meet CMS requirements. Change the language in which the education is to be printed in by using the drop down next to English. The language must be changed before selecting the education topic. Not all education topics are available in each of the languages. Left-click on the education topic to add it to the patient s education.
2 Page 2 of 6 Use the search box to locate additional education topics. There is no need to click enter. Expect a short delay before the new list of topics displays after typing has stopped. Click the Medication Leaflets tab to search for medication education. Click the + sign to the right of the Patient Education title bar to open up Krames. Click the pencil icon to open the education topic to view and make any changes. Editing of the topic will apply only to this patient. Click the printer icon to print the education. Only the Education topic title will print on the Patient Visit Summary(PVS). Education topics are to be printed and given to the patient. Click the X to remove the topic if it was selected in error or did not meet the education need. Click Full Assessment to open the Adult Education iview band and document the patient s response to the education provided. Click the star and select Personal Favorites. The star will turn yellow and the topic will be available when the Favorites button is selected. Home Medications to satisfy this requirement, Discharge Medication Reconciliation must be completed by the provider. Follow Up to satisfy this requirement, at least one Follow Up must be documented. Using Quick Picks The Patients PCP will automatically display in the Quick Picks for easy selection.
3 Page 3 of 6 More than one option can be selected in Quick Picks. These will display under Follow Up Instructions. Use the Search box to locate providers that are not in Quick Picks or Favorites. Once a provider is selected, click Modify. Modify only displays when a selection is made in Quick Picks. Using the drop downs, select the providers address and telephone number. Select from the Predefined Comments or free text in a comment. It is best practice to schedule the appointment for the patient prior to discharge. Once all the details are entered, click Save. To add the provider as a favorite, click Save as Favorite. Click the X in the upper right corner to close the box. Clicking the + sign in the upper right corner of the Follow Up title bar opens the Follow Up tool.
4 Page 4 of 6 Discharge Documentation The Nursing Discharge Summary Form is completed from the Discharge Documentation component. Click the drop-down arrow to the right of the Discharge Documentation title and select Nursing Discharge Summary Form. This form can only be accessed from this component. It is not located in the Adhoc folder. Click the + sign next to the drop down to access the Adhoc folder to document in other discharge forms such as the Expiration form. Nursing Discharge Summary form consists of three sections. Document where the patient was discharged, discharge mode and transportation used, as well as any special equipment or services that the patient went home with. Document the patients vital signs at discharge. BEFORE the follow-up appointment is scheduled, complete the LACE Index Scoring Tool. LACE Index Scoring Tool The LACE Index scoring tool identifies those patients that are at high risk for readmission or death within 30 days of discharge. The LACE tool has four questions asking about length of hospital stay, if admitted from the ED, comorbidities, and number of ED visits in the last 6 months. Click the Location in the patient s banner bar to view previous visits including ED visits. The LACE Score will be calculated automatically based on the documentation. Based on the patient s score, the follow-up appointment should be scheduled for the appropriate timeframe even if the provider requested a later timeframe. If the provider indicated an earlier timeframe than the LACE tool, the earlier time should be scheduled. Printing the Patient Discharge Instructions Click Patient Discharge Instructions at the bottom of the component list to open the Patient Visit Summary.
5 Page 5 of 6 If all the requirements are not met when the Patient Discharge Instructions are opened, the nurse will need to select an override reason from the drop down for each requirement that is not met. The override reason entered will display when the Patient Discharge Instructions are opened again if the requirement remains unmet. Hover next to the title of each of the sections in the Patient Discharge Instructions to reveal the icons to refresh the section, free text additional information and to remove the section. Use the middle icon to free text in additional information. Removing a blank section will clean up and customize the Patient Visit Summary for the patient. Instructions from the provider on Activity limitations, wound care, etc. can be free texted in the What to do next section by hovering in the section and clicking on the free text icon. There are two medication sections. The first is a list of home medications that is printed with a page break so that the patient can keep a list of medications to show to providers. The second medication section is where nursing will enter the next dose information as well as any special instructions for the patient. Hover in the When, Instructions, and Next Dose boxes to free text medication administration details. Click the Save button to save any information that has been free texted into the Patient Discharge Instructions. Click Sign/Submit to sign the form and open the Sign/Submit box. Once the Sign/Submit Note box populates, click Sign & Print to print the instructions. The Home Medication list that is printed from TASK in the toolbar is no longer needed.
6 Page 6 of 6 For questions regarding process and/or policies, please contact your unit s Clinical Educator or Clinical Informaticist. For any other questions please contact the Customer Support Center at: or
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