January 29, 2013—Diagnosis-related documentation in DEx discharge summaries
Stroke-specific care
For patients with defined diagnoses recorded in the discharge orders for the visit, providers completing the discharge summary in DEx are required to document stroke-specific care provided during the visit. The section in DEx displays for patients with one or more of the following diagnoses at discharge: cerebrovascular accident (CVA), transient cerebral ischemia (TIA), or ischemic stroke.
Key Elements:
All of the following information is required:
The date and time the patient was last known to be well or at a pre-stroke baseline
The date and time that neurological symptoms were first discovered
The date and time the initial head CT was performed at MGH, if done
The date and time intravenous tPA therapy was started, if done
VTE prophylaxis implementation during the inpatient visit
Whether antiplatelet therapy was initiated by the end of hospital day 2
Whether the patient was evaluated for dysphagia prior to any oral intake of food, medications, or fluids
Whether the patient was evaluated for rehabilitation by physical and/or occupational therapy
Whether cardiac telemetry or 24-hour Holter monitoring showed evidence of paroxysmal, persistent, or permanent atrial fibrillation, or atrial flutter
The final section displays data from the discharge orders for the visit regarding orders for antithrombotic and statin medications. The information is included in the DEx printout and DEx in the Reports section of the CAS Results.
Venous Thromboembolism (VTE) Management
For patients with defined diagnoses at discharge, providers completing the discharge summary in DEx are required to document VTE management measures for the visit. The section in DEx displays for patients with one or more of the following diagnoses at discharge: deep venous thrombosis, pulmonary embolism, or thrombosis.
Key Elements:
All of the following information is required:
Whether the VTE diagnosis was confirmed prior to or during the admission
If confirmed during the visit, what study or test was used to confirm the VTE diagnosis—if known, providers can select from available reports from cardiology and radiology, or document the test or report manually
The information is included in the printout of the DEx discharge summary, and DEx discharge summaries are accessible from CAS Results.
Presentations
Instructions for DEx, Discharge Orders, and CAS Results
Discharge Summaries in DEx (click the link for Editing the Specific Information (field by field), then Stroke Specific Care or Venous Thromboembolism (VTE) Management)
Completing the Face Sheet (see the section Enter the principal and associated diagnoses)
See also: