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.
This form can be completed by an RN or NP. For additional information, see the Overview of Discharge Orders, Instructions, and the Patient Care Referral Form.
Required information is flagged with a red asterisk *
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.
The nursing note is NOT part of the discharge paperwork given to the patient. It is sent to VNA, SNF, etc. and is part of the electronic record.
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.
If you haven't already:
Select the patient and click Face Sheet Discharge (ALT+F) or Discharge (ALT+G).
Click the Nsg D/C Note folder to access the form.
Complete the form:
The dates of admission and discharge are automatically filled from the current patient record.
Type the unit the patient is being discharged from.
Select the situation that the patient is discharged to. If Other, press TAB and type a description in the field provided, then click OK.
Type a name and description of the person accompanying the discharged patient, and descriptions of the patient's discharge condition; any nursing diagnoses or interventions, and a description of current precautions if applicable. To work in a larger text area, click the field, then click Zoom. To return to the order, click OK.
Select an item from the Discharged Via list. If Other, press TAB and type a description in the field provided, then click OK.
For infants, check Discharged with car seat as required.
Type the discharge address and telephone number. If the patient is being discharged to home, click Default Home Address Phone to automatically fill in the fields from the patient's demographic record. To work in a larger text area, click the field, then click Zoom. To return to the order, click OK.
Type to describe the current nursing assessment and interventions. Include only current active problems. A summary of the entire hospitalization is included in DEx and is not needed here. Describe the individualized plan of care to summarize which interventions were successful and which were not. Be sure to document the presence and plan of care for any lines, tubes, or drains.
Type to describe any precautions that should be observed on discharge to another care facility. To work in a larger text area, click the field, then click Zoom. To return to the order, click OK.
If the patient is being discharged to another care facility, and there was a warm handoff to that facility:
Click to check Provided to facility in the Warn Handoff section.
Type the name of the clinician contacted
Type the date of contact, or click 
to open the calendar and select the date.
Click HHA/VNA More Info for information on identifying and processing Home Health or Visiting Nurse referrals.
Click Print for a paper copy of the step-by-step instructions.
Click Return to close the display.
Hold the mouse pointer over the 
for this information: For transfers to a facility print and
include with discharge paperwork for EMTs/transport; for VNA, print
and fax to agency
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 other Instructions 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:
Click Save.
Type your signing key in the field provided.
Click Yes or No to indicate whether the patient is ready to be discharged. If Yes, click one or more checkboxes to sign off on the discharge.
Click OK (ALT+O).
The details of the patient's order for life-sustaining treatment (code status) print automatically on the paper copy of the Nursing Discharge Note. The information is therefore available in the discharge documentation in the patient's EHR (electronic health record = Results). See also: