Electronic Discharge Process for Nurses

Transcription

1 Electronic Discharge Process for Nurses When you receive a discharge order Go to Overviews Tab on the Menu. Click Discharge Overview Tab to view the patient s status for discharge readiness. Yellow Arrows denote items that the physician is responsible for entering. Red Circle indicates the items that the nurse should complete. Completion of Radio Buttons: Discharge Order autocompletes when the provider enters the discharge order Diagnosis provider must manually complete when all diagnoses are documented Patient Education nurse to manually complete when all patient education is completed Follow-up nurse to manually complete when follow up appointments have been made or appointment information has been sent via OrderComm for evening and weekend discharges. DC Meds Rec autocompletes when the provider completes discharge meds reconciliation Documents provider must manually complete when discharge note is completed Procedures provider must manually complete when all procedures performed during this visit are documented *Provider can be Physician, Nurse Practitioner, or Physician Assistant Note: The patient should not be discharged unless all radio buttons are completely filled. The completion of the radio buttons communicates to the team that all aspects of the discharge process is complete and the patient is ready for discharge.

2 To Access Discharge Education: Click on the + in the Patient Education area. Or click on the Patient Education link - this link is only available if you have a patient chart open Patient Education window opens You can type into the search field. You may have to change from begins to contains. You also want to make sure the All folder is selected. In the Language field, you can use the drop down to change the language to Spanish or other languages if needed.

3 Diagnosis specific search: Discharge Instructions folder: You can select diagnosis specific education or discharge education. To find diagnosis related education topics, type the education topic into the search window; you can pick which topics you would like to print. Preview the selected education documents by double clicking on the highlighted topic. This action will move the instructions to the Selected Instructions box. You can then add or delete topics as necessary. **To avoid printing too much information, only choose the top 2-3 diagnoses and any new medications pertinent to this admission. For example, if your patient is diabetic but is well controlled and was not admitted for diabetic complications there is no need to print off a bunch of diabetes related instructions. You can remove a topic from the list by clicking on the red X to the left of the topic. Once you have decided which topics you would like click Save. This saves the education document as part of the discharge instructions.

4 If there is a topic that you use frequently, simply right click the topic & choose Add to Favorites. This will make finding frequently used items a little easier to find. If it is a topic frequently used by your department, you can choose Add to Departmental Favorites. If you made a change on the document by adding in physician specific instructions (see below note), you can choose Save as Personal Custom Instruction so you will have this form readily available to you. This will decrease your need to type the same information over & over if it is something you are commonly adding or changing. Select Print Single Instruction to print the individual education document prior to discharge. ***NOTE: To amend a document or add a note to the form, you may type directly into the document by clicking within the form on the right hand side of the window. This allows any special instructions specific to the patient to be added easily. If you are supplementing the discharge instructions with forms from the intranet education site, you will want to type a note about it on the bottom of the Discharge Instructions page. ***NOTE: Language Translation is only available for included text. The results for your education topics can now be seen in Discharge Overview.

5 After all education is selected click the patient education radio button to communicate that all education is complete. To schedule a follow up appointment select each unscheduled follow up appointment. The physician can order a follow up appointment with an outside provider instructing the patient to make the appointment, or a follow up appointment with an inside provider for a specified time, or a follow up appointment that is already scheduled. The nurse/clerk must only schedule the appointment for the follow up appointment with an inside provider for a specified time. When the appointment is made document the date/time in the On/At field above. The date/time of this appointment will now display in the Selected Follow up window. Click Save. If an appointment cannot be made because the call center is closed, or if the scheduling department is not able to make the appointment, select a predefined comment and double click to move to the edit comment field or free text a comment in the edit comment field. The clerk/nurse will fax/ordercomm the Discharge Instructions (do not include education) to the call center when the discharge instructions are printed.

6 When the follow up appointment is documented, click the Follow-up radio button to complete. When all radio buttons are filled, click the Depart link to print the discharge instructions, education, medication reconciliation & follow up appointments. First, click the box beside the yellow highlighted line Patient Verbalizes understanding of instructions given and then click the icon beside Sign & Print. This will automatically print all forms, save to the medical record, and take you back to the Overviews Screen. Note: If education was provided prior to discharge, deselect by clicking the print icon by the education so this document will not print again.

7 Do not ask the patient if they would like an electronic copy of the discharge instructions. However, if the patient requests an electronic copy of the discharge instructions contact HIMS at anytime during the day or night to provide a flash drive with the Discharge Instructions. See workflow for electronic discharge instructions at the end of this document. Reminder: If the patient is discharged after routine business hours and the follow up appointment was not made prior to discharge send the discharge instructions (excluding education) to the Call Center by OrderComm so the follow up appointment can be scheduled by the Call Center. The Call Center should notify the patient of the follow up appointment date/time. The last page of the discharge instructions should be signed by the patient and placed in the paper chart to be scanned into the electronic medical record after discharge. You have now completed the electronic discharge process.

8 Nurse checks e-copy request indicator on Depart screen and calls 2672 HIMS Staff logs Unit, Contact Name & Phone, Patient Name, MRN, Date, Time, expected Time of Departure System saves D/C Instructions as.pdf to network drive \\hicerner\cerndischarge HIMS Staff retrieves and inserts jump drive into workstation USB port Nurse Accesses EHR Depart Screen HIMS Staff selects shortcut to drive from desktop and opens.pdf for correct patient HIMS Staff verifies name on.pdf then saves file to jump drive Patient Requests Electronic Copy of D/C Instruction YES E-Discharge Instruction Workflow HIMS Staff verifies file has been saved by opening.pdf on jump drive HIMS Staff uses marker to write initials and date on jump drive and contacts unit for pick up NO D/C Instructions are saved to EHR and printed by Nurse Unit staff picks up jump drive and signs/dates/times log Unit staff delivers jump drive to patient Patient signs back page of D/C Instructions and Nurse files in paper chart Patient given hard copy of D/C Instructions by Nurse Signed back page of D/C Instructions Scanned into Patient s EHR by HIMS