From the Office of Clinical Informatics Cerner Millennium Provider Discharge Workflow September 8, 2018

Transcription

1 Cerner Millennium The nursing and provider Discharge MPage facilitates and integrated workflow and the production of an aligned Patient Visit Summary and Discharge Summary. Discharge MPage The Discharge MPage guides the clinician through activities that are required to discharge a patient and communicate their care. Six of the elements are required and contain soft stops or gap checkers, which provide visual indicators to the clinician that it s either been met or not met. The Discharge MPage is designed to collect the hospital course over time, and then create a Discharge Summary at the time of discharge. The hospital course component is multi-contributor and unique to this MPage. It will display all contributions to during the current admission until a Discharge Summary is created and saved. If there is any uncertainty that a patient will be discharged, save the Discharge Summary, don t sign/submit. Saved notes in Dyn Doc can have in-line edits and auto-populated data can be refreshed. If a patient s condition changes after signing a Discharge Summary and the discharge is cancelled, the Discharge Summary note should be marked in error and a new Discharge Summary created. The information in the old summary can be tagged and inserted into the new summary. Adding the Discharge ViewPoint (aka MPage) to the Provider View: Click the Provider View in the menu or the house icon. Click the plus + sign. Click Discharge. NOTE: You can organize the tabs (ViewPoints) in the provider view by dragging and dropping. You can also organize the components in the Discharge MPage by dragging and dropping. Consider grouping the required elements together. The components with a gap checker are identified with a red asterisk or a green check mark. The green checkmark indicates the item has been addressed at least once. The red asterisk indicates that the requirement has not yet been satisfied. Each component tells you what s missing or what needs to be completed. Prior to opening a note template, such as the Discharge Summary, all required elements must be addressed or a rationale as to why not is needed.

2 Page 2 of 6 Provider Only Components: The discharge process is multidisciplinary. However, the following required elements must be entered/completed by the physician, physician assistant, or advanced practice nurse Discharge Quality Measures These are the quality measures previously found in the Discharge Order PowerNote. They will now be discretely captured through a PowerForm and available for reporting, eliminating the need for manual chart abstraction. Only providers have access to the PowerForm from their MPage. The down arrow opens the Discharge Quality Measure PowerForm. The plus + link navigates to Results Review. Click the down arrow to open the PowerForm and select the appropriate measure. Complete the documentation, then click the blue return button; repeat as needed. Once all appropriate measures are charted, click the green checkmark button in left upper corner. Problem List This will always be satisfied by the admission diagnosis; update if needed. Orders A discharge order is required, which must be associated with the primary discharge diagnosis. Navigate to the Order Profile component and click the + link. Highlight Discharge (DX), then click Submit. The order populates the Shopping Cart. Click the shopping cart to open the Orders for Signature box. Click the Diagnosis to associate it to the order. Click Sign and complete the missing order details. Click the House icon to go back the Discharge MPage.

3 From the Office of Clinical Informatics Provider- Discharge Workflow ] Discharge Medications Discharge Med Rec can only be completed by the provider. The process is unchanged. Page 3 of 6 Multidisciplinary Components: The following elements may be documented by either the provider or nurse Follow-up This is the same tool currently in use, but is now available on the MPage. Documentation will populate the DC and Patient Summaries. Patient Education Suggested items will populate based on the problem list and at least one must be chosen. The title will flow to the Discharge Summary. Creating the Discharge Summary Using Dynamic Documentation Items the provider must enter in the note template: Follow up Recommendations (for the ongoing care provider) Discharge Disposition Condition at Discharge Discharge Instructions: These are created for the patient and populate both, the discharge and the patient visit summaries. This is a free text component of the Discharge MPage. It is NOT multi-contributor. The provider will see his/her own documentation only. This is not used by any other note template and is not erased by the creation of other clinical notes. Time Spent on Discharge (if > 30 minutes) Share Free Text MPage Components: These free text components are shared with other MPages. Once a note is created using Dyn Doc, the information in these components is erased. Physical Exam History of Present Illness (HPI) (Optional) Assessment and Plan.

4 Page 4 of 6 Hospital Course: This is a multi-contributor free text component that is only linked to the Discharge Summary template. This allows multiple users to contribute to the hospital course narrative throughout the patient s stay. The text with in the hospital course MPage component will remain face up and editable within the discharge workflow MPage until the discharge summary template is signed. IMPORTANT: Once the Discharge Summary template is launched and the note saved, the link between this component and the discharge summary template is broken and future edits should be made directly into the note. While information can continue to be collected within this component, it will not auto-populate the Discharge Summary. Items auto-populating the note template: These may be modified, if needed Problems addressed this visit Activity Ongoing (i.e. chronic) problems Procedures during this visit Pending Labs/Rads Tagged labs Attending Physician Discharge Medications Primary Care Provider (PCP) Allergies Date of Admission Follow up/appointments Diet Patient Education Titles Code Status Available Note Templates Two Note Templates can be used, depending on if the hospital course will be completed within Dynamic Documentation at the time of discharge. Discharge Summary Template Use this template to complete documentation of the hospital course at the time of discharge. This template supports multiple contributors if the note is saved and not signed. However, once the note is saved, the link between the MPage components and the template is broken and the note will not update with new documentation. This requires you to go into the note to update narrative text once the note is saved. Auto-populated data will NOT automatically refresh upon opening a saved, unsigned Discharge Summary. Each item must be refreshed from within the note.

5 Provider- Discharge Workflow ] Page 5 of 6 Discharge Order Template Use this template when dictating as the note it is sent to transcription services. Use this template if you plan to complete the hospital course later through the addend process. IMPORTANT: The Discharge Order template type does not support multiple contributors. It contains all the items in the Discharge Summary template except the hospital course. Tagging must be done prior to creating a note with this template, as tagging does not work in the addend/modify process. Using Templates: Key Concepts Required Elements Regardless of the Note Template used, if any required elements are missing, a reason will be required, prior to the template opening. Entering Data and Saving Documents A variety of data entry methods can be used in free-text fields. Examples include: M*Modal Fluency Direct Speech-to-Text, Tagging, Auto Text, and direct typing. Choose Save, not Sign/Submit, if there is any uncertainty regarding whether the patient is ready to be discharged. To update a saved Discharge Summary: Click the Discharge Summary link in your menu, just as if starting a new note. Click Continue in the pop up. Previously auto-populated data will NOT automatically refresh. Therefore, each component must be manually refreshed. Do this by clicking the refresh button within each component. Be sure to refresh Discharge Medications, Pending Laboratory and Radiology, and any other item (including tagged labs, allergies, follow up appointments, Problems etc.) that may have changed since the discharge summary was started.

6 Page 6 of 6 Documenting the Hospital Course after Discharge via Dictation or Dyn Doc Choose the Discharge Order Note Template Click the Discharge Order Note link at the bottom of the MPage. If any required components of the MPage lack documentation, a pop-up will requesting a rationale. Complete the manual fields the same as for a Discharge Summary. Tag laboratory and diagnostic results and other important information. Add to the note. Labs will automatically populate. Drag and drop other information to the appropriate location within the note. Click Sign/Submit. Option 1: Add the Hospital Course via PowerChart: Find the signed Discharge Order Note and right-click in the body of the note. Select Modify. Add the information to the Add Addendum section at the bottom of the template. Change the NoteType to Discharge Summary, so that charting requirements are met. Click the blue link which launches the note details. Change the Note Type to Discharge Summary. Update the title, if necessary. Click Sign to return to the template. Click Sign/Submit. Option 2: Add the Hospital Course via Dictation: Dictate the hospital course using the correct work type (It is not changed by this process). Transcription will combine the hospital course with the Discharge Order Note and send it to the Message Center Inbox as a Discharge Summary for final signature. DOCUMENT DISTRIBUTION The Discharge Summary and Discharge Order Notes are automatically sent to the PCP. Communicate the note to additional providers via the signature pane or provider letter. Transcription services will send notes to additional providers if their full information is dictated when creating the hospital course. NOTE: EMHS recommends the use of M*Modal Fluency Direct speech-to-text. 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