You have 62 year old patient who is being discharged to a SNF (Skilled Nursing Facility) in three (3) days.

Transcription

1 Scenario You have 62 year old patient who is being discharged to a SNF (Skilled Nursing Facility) in three (3) days. You want the discharge planner to consult with the patient and plan for the pending discharge. You proceed to continue the discharge process. You notice that the Document Medication by History has not been completed; you can complete Document Medication by History by clicking the corresponding button then selecting No Known Home Medication, Unable to Obtain Information, or by Add(ing) and filling in their home medications. Your patient has home medication of Lasix 20mg, Ibuprofen 400mg which they take 2 tabs, q 4hrs for pain. You want to continue these medications as well as provide a new prescription for Percocet 5/325mg oral tab, 1 2 tabs, q6hrs, prn, for pain. Process steps 1. Sign in to PowerChart and select your patient. 2. Click on the orders component. The orders window appears. 3. Click on the Add button the Add Order window displays. 4. Confirm that type is listed as All Orders. 5. Type Cons in the Find box. Last edited: 4/15/11 Page 1 of 5 Clarity@pph.org

2 6. Search for and select Consult CRM. 7. Order sentence window opens, click Discharge Planning. Click OK ; the order sentences close. 8. Click Done button; the Order Catalog closes. 9. Modify Order Details for Consult CRM. In special instructions type: o o Discharge expected 3days from today Discharge to Board and Care; PT Eval and treat. 10. Click Sign and refresh. Notice order is present in the order profile (Navigator) under consults Home Medication Add your patient s home medication to Document Medication by History. See scenario above (In the future this step will be completed prior to performing the discharge process.) 1. Click on the Discharge icon on the action toolbar. The Discharge Process window opens (clocking time may be prolonged as it is pulling information from multiple areas). 2. Notice that there are three (3) yellow highlighted fields; Diagnosis, Medication Reconciliation, and Follow up. These areas are required for the MD to address. (In the future, at go live, the fields Discharge Instructions and Orders will also be highlighted yellow and require addressing by the MD). 3. Click on pencil icon on Diagnosis line of Navigator; the Discharge Diagnosis window opens (this segment is required to be address by the MD). All discharges required at least one diagnosis (ICD9 or Snomed) 4. Click +Add icon 5. Type Bronchitis in the diagnosis search field. 6. Click binoculars icon to get diagnosis. 7. Click on Bronchitis then click OK. 8. Address remaining fields (they should be pre filled with correct information). Last edited: 4/15/11 Page 2 of 5 Clarity@pph.org

3 9. Click OK or Ok & New to add another diagnosis. Click Close. Notice that there is a check mark on Diagnosis line, indicating that area has been addressed. Medication Reconciliation 1. Click on pencil icon on Medication Reconciliation line of Navigator; the Medication Reconciliation Window opens (this segment is required to be address by the MD). Notice that all medications are preselected as Do Not Continue at Discharge; however, most medications can be changed to continue after discharge. IV s and IV administered drugs can not be continued by clicking on continue after discharge, they will need to have prescription written to continue with home health. 2. Click to continue Lasix and Ibuprofen (Hint: click on medication listed as documented). 3. Add prescription for Percocet and enter order details (Hint: change All Orders field to RX). (Please: select Do Not Send, Called to Pharmacy on printing field located just right and above the order details). 4. Select Reconcile and Sign button. The Medication Reconciliation window closes. Notice that there is a check mark on Medication Reconciliation line, indicating that area has been addressed. Follow Up 1. Click on pencil icon on Follow up line of Navigator. The Patient Education/Follow up tab window opens (this segment is required to be address by the MD). Have patient follow up with you (use your real name not training name) in six (6) weeks for exam. 2. Click on Sign button. The Follow up window closes. (Note: Your name is now in the navigator was well as Patient Summary screen at right as when to follow up and purpose of visit). Discharge Instructions 1. Click on pencil icon on Discharge Instructions Form line of Navigator (this segment is required to be address by the MD). Last edited: 4/15/11 Page 3 of 5 Clarity@pph.org

4 This section is use for the provider to instruct their patient when they may return to certain activities. You want your patient to follow these instructions: 1) Type in, Regular Diet 2) Click, Activity as tolerated; 4 days 3) Click, Shower, Now 4) Click, Sports, 6 weeks 5) Click, Tub Bath, 6 weeks 6) Click, Sexual Activity, 6 weeks 7) Click, Work/School, 6 weeks 8) Click, Heavy lifting, 6 weeks 9) Click, House work, 6 weeks 10) Click, Driving, 2 weeks 11) Type in special Activity Instructions : May drive after discharged from Board and Care, if not taking narcotics Discharge Equipment and Treatments will be addressed by discharge planner. 2. Click on green check mark icon on tool bar to discharge instructions to sign. Notice that there is a check mark on Discharge Instructions Form line, indicating that area has been addressed. Orders 1. Click on pencil icon on Orders line of Navigator (this segment is required to be address by the MD). Notice that there is a check mark on Orders. This section is addressed though out the patient s stay as orders are added. Last edited: 4/15/11 Page 4 of 5 Clarity@pph.org

5 2. Type Discharge Orders PowerPlan Discharge to Skilled Nursing Facility outside of PPH. Have IV saline lock and Urinary catheter removed. Have PT eval and treat for discharge Address Cardiology Discharge Core Measures (Hint: select each order sentence, right click Modify Plan Order address prompts and click green check mark sign documentation). on each open window to 3. Click Orders for Signature 4. Click Sign 5. Click Done ; you return to discharge screen. Sign and Print 1. Click on pencil icon on Sign and Print line of Navigator. The Discharge window closes. 2. Click on Task on the task tool bar. 3. Select Reports. 4. Select Discharge Orders. 5. Choose a Printer Destination. 6. Select Print. Last edited: 4/15/11 Page 5 of 5 Clarity@pph.org