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 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 information 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 documentation of decisions regarding the transition of care at discharge qualifies as meaningful use of electronic health records, as defined by the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS). The Core Measures folder prompts for this documentation based on several diagnoses related to heart disease and stroke in adults, as well as pediatric asthma, and pneumonia for all patients.
If you haven't already:
Select the patient and click Face Sheet Discharge (ALT+F) or Discharge (ALT+G).
If needed, click 
Core Measures in the folder list to access the form.
Heart Failure: For patients 18 years an older, if the discharge record includes any heart failure diagnoses, OR if the patient is located on a care unit where this information is required, the question"Patient has history or symptoms of Heart Failure?" is displayed on the Heart Failure tab.
For all heart failure diagnoses except atrial fibrillation, "yes" is selected automatically. You must select the Yes or No option for atrial fibrillation, as well as any other diagnosis that is not defined as heart failure. (The question can be required based on the patient's care unit, rather than the diagnosis.)
When the patient has a history or symptoms of heart failure, type to enter the target dry weight (lbs) for the patient. Enter a range by separating the upper and lower limits with a dash (-). This information is included in the PHPCP.
When the patient has a history or symptoms of heart failure, click the option in the drop-down list to indicate whether the patient has an LV ejection fraction of less than 40%, or evidence if moderate to severe systolic dysfunction.
When the patient has a history or symptoms of heart failure, and either an LV ejection fraction of less than 40%, or evidence if moderate to severe systolic dysfunction, you are required to answer Yes or No to indicate whether specific evidence-based beta blockers will be ordered for patient at discharge. If the answer is Yes, and there is no discharge order for the medications listed, you are prompted to write an order. Click Cancel at the prompt to change the answer to No if appropriate; otherwise, click Change Meds to open the discharge medications list and write the order. See Ordering Medications for Discharge.
When the patient has a history or symptoms of heart failure, and either an LV ejection fraction of less than 40%, or evidence if moderate to severe systolic dysfunction, you are required to answer Yes or No to indicate whether angiotensin converting enzyme inhibitors (ACEI) and/or angiotensin receptor blockers (ARB) will be ordered for patient at discharge. If the answer is No, select a reason from the associated drop-down list. If Yes, remember to write an order for the applicable ACEIs and/or ARBs; see Ordering Medications for Discharge.
Stroke: For patients 18 years an older, if any of the diagnoses is stroke-related, the statement "Patient has diagnosis consistent with Stroke or TIA or Brain Hemorrhage?" is presented on the Stroke tab of the Core Measures folder.
For hemorrhagic stroke diagnoses, you must select the Yes or No option; for ischemic stroke diagnoses, "yes" is selected automatically and is not editable.
A diagnosis of ischemic stroke also triggers a tab for Ischemic Stroke and/or TIA, which includes several additional fields of required information, with a link to clinical guidelines in the Partners Handbook from MGH Neurosciences. You must indicate whether an antithrombotic (antiplatelet or anticoagulant) be ordered for the patient at discharge, and additionally, whether a statin will be ordered.
If you answer "No" to either medication question, you are required to select a medical contraindication for not ordering the treatment for discharge.
Comorbidity: When both stroke and atrial fibrillation are listed as diagnoses, you must indicate whether you are ordering anticoagulants. If not, you must provide a reason
COPD: Core measure monitoring for chronic obstructive pulmonary disease (COPD) is required for all adult patients who are discharged with one or more defined diagnoses. The initial question is "Was the patient admitted due to COPD exacerbation or COPD related condition?"
Depending on the diagnosis itself, and whether it is principal or associated, the initial question is either answered Yes by default and cannot be changed, or requires the ordering provider to select a Yes or No answer. See the COPD core measures matrix.
If the first question is answered Yes, you must answer the remaining questions. These core measures are based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Criteria for COPD Management. To access either a pocket guide or the full report on the GOLD criteria, click the link at the bottom of the tab.
When the first question is answered Yes, the discharging nurse is required to document on the Post Hospital Patient Care Plan (PHPCP) whether the patient has received COPD Success Tracker and MGH COPD Education sheet.
Click to select Yes or No to answer the question of whether you discharging the patient with an order for a long-acting bronchodilator. If not, you must select an option from the Reason for not ordering drop-down list.
Click to select Yes, No, or Unknown to answer the
question "Has patient ever had pulmonary function tests (PFT)
performed?" Answering No or Unknown for the PFT question inserts
the following into the Discharge Instructions and Plans for Follow-up
section of DEx:
COPD: Based on clinical impression,
the patient may have COPD but has no known Pulmonary Function Testing
in the past. It is recommended that pulmonary function testing
(consider full testing, spirometry with bronchodilators at a minimum)
be scheduled for this patient as an outpatient.
Click to select Yes or No to indicate whether the patient has been or will be scheduled for pulmonary rehabilitation as an outpatient. Clicking the link beneath the rehab question displays a list of pulmonary rehabilitation programs for outpatients offered in the state of Massachusetts. You can print it for the patient to decide the most suitable option.
If you answer No to the rehab question, you are prompted to reconsider. Clicking the button to order outpatient pulmonary rehab brings you to the discharge Services folder; clicking the button for the list displays a list of pulmonary rehabilitation programs for outpatients offered in the state of Massachusetts; canceling closes the prompt. See Writing Orders for Services at Discharge.
Pediatric Asthma: For all pediatric patients with some principal or associated asthma-related diagnoses, the question "Patient has history or symptoms of Asthma (pediatric patients only)?" is answered Yes by default, and cannot be changed. Any associated asthma-related diagnosis requires the ordering provider to answer the question.
Pneumonia: For all adult patients with a principal diagnosis of pneumonia, the question "Does the patient have a diagnosis of pneumonia during this admission?" is answered Yes by default and cannot be changed. Any associated diagnosis of pneumonia requires the ordering provider to answer the question.
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).
Post-Hospital Care Plan Patient Education: When the diagnoses of heart failure, stroke, TIA, or brain hemorrhage are listed, the information is carried over to the post hospital patient care plan in the nursing discharge instructions forms. Nursing is required to document that the patient has received the appropriate handouts for discharge. See Completing the Post Hospital Patient Care Plan.