November 12, 2013—Enhancements to Discharge Orders
Providing patients and their outpatient providers with accurate and timely information at the time of discharge is important for a safe and smooth transition of care. The following POE discharge module enhancements were made to allow for accurate and up-to-date information for the patients discharge paperwork that can also to be sent electronically to their outpatient providers. This fulfills important requirements set by the Centers for Medicare & Medicaid Services (CMS) to demonstrate meaningful use of the EHR (electronic health record).
Key Features:
All significant operations and procedures performed during the inpatient stay must be listed on the Face Sheet. Because the data must be linked to specific clinical terminology, making an entry is similar to looking up a diagnosis. Look up "none" if applicable.
The data for operations and procedures is transmitted automatically to the DEx discharge summary.
Labs/Imaging/Other Tests is also required; enter None if applicable. Type the name of each relevant test or exam, and when needed, include the result in language the patient can understand. Remember to include any findings that need follow-up.
Order Info now includes a list of post-discharge goals. This list documents the care plan for the patient, family, and/or caregiver. List each goal along with the instructions or intervention intended to achieve that goal. Continuity of Care is listed by default with the instruction to attend all post-discharge appointments; you can delete or edit this as needed. All clinicians with discharge authorization can view the goals and instructions in a new Care Plan folder.
Information from the Operations/Procedures, Labs/Imaging/Other, and Post-Discharge Goals/Care Plan print on the patient's discharge paperwork. The patient's RN prints and reviews the post-hospital patient care plan with the patient, family, or caregiver as appropriate.
To accommodate changes to the Face Sheet for encoded operations and procedures and the more detailed lab/imaging list, core measures now reside in a separate folder.
Instructions:
Presentation: Enhancements to the Face Sheet and Discharge Orders
See also: