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.
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 Post Hosp Pt Care Plan folder to access the form.
The printed copy of the post-hospital care plan includes a statement to inform patients that they may be contacted for a survey regarding their admission to MGH.
Complete the form:
The discharge diagnoses, diet, activity, treatments, and additional orders, instructions, and equipment, and instructions for follow-up care entered by the MD, NP, PA, or CNM fill in automatically.
If the patient is discharged with equipment and/or supplies, type a description of the items. To work in a larger text area, click the field, then click Zoom. To return to the order, click OK. (If the patient will be acquiring equipment and/or supplies post-discharge, and prescriptions are needed, see Writing Prescriptions for Equipment and Supplies for Discharge.)
Type specific instructions for the patient at discharge in the Nursing Instructions at Discharge field. All entries in the PHPCP are provided to the patient; be sure to use patient-friendly language. As applicable. instructions should address pain management, activity, diet, medication safety and education, wound care, safety precautions, infection, and educational handouts. Type none when applicable. To work in a larger text area, click the field, then click Zoom. To return to the order, click OK.
The monitored core measure information entered by the MD, NP, PA, or CNM fills in automatically.
For adults with a history or symptoms of heart failure, click to check the box to indicate that the patient, family, and/or caregiver has been given the appropriate printed information. Clicking the Patient/Family Education folder opens a web page for the MGH Patient and Family Education Materials & Resources on the Patient Care Services intranet.
For patients 18 years or older with a history or symptoms of stroke, click to check the box to indicate that the patient, family, and/or caregiver has been given the appropriate printed information. Clicking the link beneath the checkbox opens the Neurology - Stroke page in the Partners Handbook.
For patients 18 years or older with a discharge order for warfarin (Coumadin), click to check the statement and affirm that the patient, family, and/or caregiver has been given the appropriate printed information.
Clicking the Patient/Family Education folder opens a web page for the MGH Patient and Family Education Materials & Resources on the Patient Care Services intranet.
Checking off this warfarin education option inserts the following statement into the printed PHPCP: "Patient/Family/Caregiver received the MGH Warfarin Education Booklet and/or MGH Discharge Instruction/Materials which address 1) Compliance with taking warfarin as instructed and the importance of monitoring warfarin with scheduled PT/INR blood draws, 2) Dietary Advice including maintaining consistent amounts of vitamin K in foods and avoiding major changes in diet or to notify caregiver before changing dietary habits 3) Follow-Up Monitoring with information about plans for post-discharge monitoring of warfarin 4) Potential for Adverse Drug Reactions and/or Interactions while on warfarin such as the increased risk for bleeding, the potential for diet and medications to affect the PT/INR lab values, and the importance of not changing medications (prescription or over-the-counter) without advice of MD or pharmacist."
To include the statement that an asthma action plan has been given to and reviewed with the patient and family, click the Yes option; if the patient does not get an asthma action plan, click the No option.
If there is an asthma action plan, select the Yes option from the drop-down list to indicate that a copy of the plan has been printed and placed in the permanent medical record. If there is no copy in the medical record, select the no option, then type the reason for the omission when prompted.
For patients 18 years or older with a diagnosis during the admission of pneumonia, click to check the box to indicate that the patient, family, and/or caregiver has been given the appropriate printed patient education. Clicking the link beneath the checkbox opens the Respiratory - Pneumonia Education page in the Partners Handbook.
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 Post Hospital Care Plan. The information is therefore available in the discharge documentation in the patient's EHR (electronic health record = Results). See also: