Completing the Face Sheet

To help clinicians recall what will be seen by the patient, each field with information entered that prints on the Post-Hospital Patient Care Plan (PHPCP) is flagged with the

icon. Please keep in mind that information on the PHPCP should be patient-friendly, phrased to be easily understood by people who don't have medical training.

Face Sheet Discharge Orders and Instructions are not available in the newborn nurseries. You cannot access the forms, even if you select a patient from the associated maternity unit lists or from patient lookup.

Patient eloped/left AMA (against medical advice): If applicable, click to check.

See Writing Discharge Summaries in DEx.

Type at least a few of the first letters of the last name of the provider in the text field.
Click Search.
Click to select a name from the Provider Lookup results. You can select “take as typed” if none of the results is the provider you want.
Click OK (ALT+O).
Sign to save the discharge orders. See Signing Discharge Orders.

The attending from the EMPI (Enterprise Master Patient Index) is the default provider to contact regarding the hospital stay. The EMPI draws this data from PATCOM, the MGH patient admitting system. If this is not correct, look up the name:

Type at least a few of the first letters of the last name of the provider in the text field.
Click Search.
Click to select a name from the Provider Lookup results. A phone number from the MGH provider database is included if available.
Click OK (ALT+O).
Sign to save the discharge orders. See Signing Discharge Orders.

Once the Face Sheet is saved, changes made to the attending in the EMPI do not carry over automatically. To change the name, you can look up the attending as described above; or to update with current EMPI data, select and delete the entry, save the Face Sheet, and reopen the discharge orders.

Both fields for diagnoses on discharge are required, while only the primary diagnosis is required on admission. If there is no associated diagnosis on discharge, you must look up "None" to satisfy the requirement. See below for diagnosis lookup.

To copy the current primary inpatient diagnosis, click <<Add<< between the discharge field on the left and the diagnosis for the visit on the right.
To copy one or more current inpatient associated diagnoses, click one or more checkboxes in the list on the right, then click <<Add<< between the discharge field on the left and the diagnosis for the visit on the right.
To look up a diagnosis, or edit the existing entry, click one of the discharge diagnosis fields on the right, or click the link above the field. The primary diagnosis must be filled first.

Type at least the first three (3) letters of the diagnosis. For more than one associated diagnosis, you can type criteria for each, separated by commas. You can record only a single principal diagnosis.
Press ENTER or click Search. Diagnoses matching your criteria are listed on the right.
For associated diagnoses, multiple search parameters will generate multiple sets of results, one for each parameter. Select from one set of results (which may be None of the following) to be presented with the next.
To highlight a diagnosis for selection, click its line or press the down/up arrows. Highlight Take as typed to enter the diagnosis as you typed it. To highlight more than one item, hold down the CRTL key while clicking.
To search using different criteria, click None of the Following, then repeat the previous steps.
Click Add (ALT+A) or press ENTER to select the highlighted diagnoses.
Repeat the process until all diagnoses applicable to this visit are listed.
Click OK (ALT+O).
Sign to save the discharge orders. See Signing Discharge Orders.

Click on the Face Sheet (next to the Principal Diagnosis heading) to display the Discharge Diagnosis/Problems List.
Hold the mouse pointer over the row for a diagnosis to display its Snomed clinical terminology code and the date and time the diagnosis was entered or most recently modified.
To update the record:

For each diagnosis as appropriate, click in the Status column, then click to select the current status: Active or Resolved
For each diagnosis as appropriate, click the Date Diagnosed field, then type the date (mm/dd/yyyy) or click to select from the calendar

Click OK (ALT+O).
Sign to save the discharge orders. See Signing Discharge Orders.

These entries are included in the patient's discharge paperwork. The information is required; click to select None if applicable.
To look up an operation or procedure:

Click Add.
Type at least the first three (3) letters of the operation or procedure. For more than one, you can type criteria for each, separated by commas.
Press ENTER or click Search. Operations and procedures matching your criteria are listed below.
Multiple search parameters will generate multiple sets of results, one for each parameter. Select from one set of results (which may be None of the following) to be presented with the next.
To highlight a result for selection, click its line or press the down/up arrows. Highlight Take as typed to enter the procedure as you typed it. To highlight more than one item, hold down the CRTL key while clicking.
To search using different criteria, click None of the Following, then repeat the previous steps.
Click Add (ALT+A) or press ENTER to select the highlighted items.
Repeat the process until all significant operations and procedures applicable to this visit are listed. Entries are not sorted alphabetically or by date; they are listed in the order they're entered.
Click OK (ALT+O).
Sign to save the discharge orders. See Signing Discharge Orders.

To display the SNOMED code for an entry, hold the mouse pointer over its row.
Type or select the date the procedure was performed. (The calendar button shows when you click the date field.) You can enter the exact date (mm/dd/yyyy), the month and year (mm/yyyy), or the year (yyyy).
As applicable, type in the Comments column to include other information such as laterality.
To delete an entry, click its Rmv button (left column).

Include only significant studies and their results, in patient-friendly language.
Include the date and time that each test or exam was performed
This information is included in the patient's discharge paperwork
Type None if applicable
To work in a larger text area, click the field, then click Zoom. To return to the order, click OK.

Review of all medications, including Warfarin (Coumadin), is part of the reconciliation that must be completed in the Medications folder. See Completing Discharge Medication Orders.

If you would like to check your spelling, click Spell Check. When you have completed the check, click OK to close the Spell Check complete message.

Complete the Medications, Order Info, and Services forms if applicable. See also: Instructions for Discharge Orders and Instructions.

Save the changes, and finalize the orders if the patient is ready for discharge. See Signing Discharge Orders.

The details of the patient's order for life-sustaining treatment (code status) print automatically on the paper copy of the Face Sheet. The information is therefore available in the discharge documentation in the patient's EHR (electronic health record = Results). See also:

Complete the Face Sheet