The Patient Care Referral form and Certification can be completed by an MD, PA, NP, RN, or medical student. If completed by an RN or medical student, it must be cosigned. 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:
Click Face Sheet Discharge (ALT+F) or Discharge (ALT+G).
Review and update patient demographics:
Click the Pt. Demographics folder and review its information.
Type additional information and comments as needed. To work in a larger text area, click the field, then click Zoom. To return to the order, click OK.
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 discharge certification:
Click the Certification folder to access this form.
The default date of the patient's most recent physical examination is today—change the date if needed.
As needed, click Yes or No to answer all of the questions regarding awareness of the patient's diagnosis, and whether you will follow the patient after discharge.
If others will follow the patient after discharge, type a name, location, and telephone number for each provider. Click the up or down arrow on the scroll bar to the right of this section to access fields for more than one other provider.
Click Yes or No to indicate if services are needed.
Click to select one of the options to indicate the need for intermittent or continuous care that prompted this referral.
Complete other Discharge forms if applicable. See Face Sheet and 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).