Provide Anticoagulation Therapy Data for Warfarin

• The information recorded here is provided to the patient, family, and/or caregiver in the Post-Hospital Patient Care Plan, under the heading of Warfarin Instructions in the Medications section for Instructions at home.

• This form 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.

• Changes made to discharge medication orders trigger an alert for clinicians if the Patient Discharge Medications List (PDML) has already been saved and printed. See Handling the Notifications When Medications Have Changed After PDML Print. The Order Status for patients whose PDML may require reprinting is Discharge (in red).

• 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:

1. Select the patient and click Face Sheet Discharge (ALT+F) or Discharge (ALT+G).

2. If needed, click the Medications folder to access the form.

• When available for the selected patient's care unit, the Patient Discharge Medication List (PDML) is generated automatically. If prompted, click one of the buttons at the bottom of the message to continue:

• Remind Me Later (ALT+R)—The message will be closed, and presented whenever you open the Medications folder in Discharge.

• Close and Don't Remind Me (ALT+C)—The message will be closed and never presented again.

• Provide anticoagulation therapy data (Warfarin)

• You will be prompted to provide this information for applicable adult medications when you write or select the orders for discharge. To edit this information, select the line in the discharge medication list, then click Edit Anticoagulation Data.

• For information from MESAC, click MGH Anticoagulation Guidelines (ALT+A).

1. Click to select one or more reasons or ordering the medication. Scroll  to see the entire list. For Other, type the reason, then click OK (ALT+O).

2. Click to select one or more options to indicate who will be following the patient's PT-INR results post-discharge.

• If you select MGH Anticoagulation Management Services (AMS) Clinic, and the patient doesn't have an AMS consult on record for the current admission, read the consult requirement notification, then click OK (ALT+O) The form for an inpatient AMS Consult order opens. Once you click OK (ALT+O) to complete the consult order, information from that is carried over to the discharge order.

• If you select PCP/Specialist, review the information presented on prescriptions for warfarin, then click OK (ALT+O). Type the name and phone number of the provider.

• For established patients, click in the upper right to display treatment details, INR range, name and phone number of the primary AMS nurse, and links to send an email or page to AMS.

• For a receiving facility, primary care provider (PCP) or specialist, or other, type the name and contact information.

4. Click to select a duration option. For Other, type the number of months.

5. Select the target PT-INR result. For Other, type the number of seconds.

6. To indicate when the patient's first post-discharge PT-INR will be analyzed, type T for today's date, or select a future date from the calendar.

7. If appropriate, click to select either or both options to indicate that the patient is or was recently treated with antibiotics, or has a history or the potential for blood loss.

8. For patients treated for Deep Vein Thrombosis or Pulmonary Embolus:

• Click Yes or No to answer the question regarding previous or current overlap therapy. Hold the mouse pointer over the  to the left for MESAC recommendations on overlap therapy.

• If the patient previously or currently received overlap therapy, click Yes or No to answer the question about the duration of the treatment.

• If the patient did receive overlap therapy for at least 5 days, click Yes or No to answer the question about the INR result.

• If the patient did not receive overlap therapy for at least 5 days, or did not have an INR greater than or equal to 2 before the overlap therapy was discontinued, click Yes or No to answer the question regarding overlap therapy for discharge. If No, click to select a reason. Hold the mouse pointer over the  to the left for contraindications to overlap therapy.

9. Click OK (ALT+O).

• See also:

• Reconciling pre-admission (PAML), inpatient, and discharge medication orders—Side-by-side Comparison

• Reconciling pre-admission (PAML), inpatient, and discharge medication orders—Vertical Comparison View

• Writing orders for additional medications

• Providing anticoagulation therapy data (fondaparinux or enoxaparin)

• Viewing, saving, and printing the patient discharge medication list (PDML)

• Editing discharge medication orders

• Writing prescriptions for medications

• To write and print prescriptions for services, equipment, and supplies, see Writing Prescriptions for Services, Equipment, and Supplies for Discharge.

• Editing prescriptions for medications