Discharge Summaries in DEx—Editing Field-by-Field

Several fields in DEx are automatically populated with information drawn from the face sheet and discharge orders. These fields cannot be edited manually without an override, and are flagged:

If the patient will not have a face sheet/discharge order signed in Order Entry, you can override the lock and enter the information manually. See Writing a Discharge Summary For a Patient Who Will Not Have Order Entry Face Sheet/Discharge Orders For The Visit.
Discharge Orders can be signed up to 36 hours after the patient has been discharged via the PATCOM admissions system. If a discharge order exists, you should sign it or get it signed if possible. See Completing Discharge Orders.
The Face Sheet and Discharge Orders can be updated for 36 hours after they're signed. When this happens, the field in DEx is flagged with . See Updating DEx with the current Discharge Orders information.

To update fields in DEx (click the underlined link to display detailed instructions for a field; click to display all instructions.

Patient Name, Medical Record Number, and Date Of Birth—This data is from the PATCOM admissions system. Corrections must be made through PATCOM.
Summary type: General, OB (obstetric), Renal (transplant), Liver (transplant), Heart (transplant), Lung (transplant)—The summary type defaults to OB, Renal, or Liver for applicable principal diagnoses in the patient's discharge orders. OB summaries pull some information from the OB-EMR. To change the type, click 6, then click the type you want on the drop-down list.
Admission Date—Required; pulled from the discharge orders.
1. Override the/Discharge Orders Lock.
2. Click the date entry to display the popup calendar.
3. If needed, change the month displayed:
- Click 3for the previous month or 4 to display the next.
- Click the name of the month to display a list of months, then click the month.
- Click the year displayed to display a list of years, then click the year.
1. Click the day to select a date and close the calendar.

Discharge Date—Required; pulled from the discharge orders.
1. Override the/Discharge Orders Lock.
2. Click the date entry to display the popup calendar.
3. If needed, change the month displayed:
- Click 3for the previous month or 4 to display the next.
- Click the name of the month to display a list of months, then click the month.
- Click the year displayed to display a list of years, then click the year.
1. Click the day to select a date and close the calendar.
- To change the discharge date on the Face Sheet:
1. Click Orders in the CAS to access Order Entry.
2. See Completing the Face Sheet.
Patient eloped/left AMA—From the Order Entry Discharge Orders.
1. Click Orders in the CAS to access Order Entry.
2. See Completing the Face Sheet.

Principle Diagnosis, Associated Diagnoses, Significant Operations/Procedures/Tests (Include Date/Result) Performed During Hospitalization—Required; pulled from the discharge orders.
- To change the Face Sheet:
1. Click Orders in the CAS to access Order Entry.
2. See Completing the Face Sheet.
- To enter manually:
1. Override the/Discharge Orders Lock.
2. Click the entry heading. For entries that don't fit in the field display, scroll up or down to view more.
3. Type descriptions of all significant operations, procedures, and tests performed during the visit. Include dates and results when available.
- If flagged with , see Updating DEx with the current Discharge Orders information

Life-Sustaining Treatment—From the inpatient record. Update using the Life-Sustaining Treatment (LST) entry options in Order Entry.
- To edit the inpatient record:
1. Click Orders in the CAS to access Order Entry.
2. See Ordering Life Sustaining Treatment.

Allergic Reactions, Intolerances and Sensitivities—From the Partners Enterprise Allergy Repository (PEAR). Update using the Allergy entry options in Order Entry or the LMR.
- To add an allergy record to the PEAR via Order Entry:
1. Click Orders in the CAS to access Order Entry.
2. Write an allergy order. See Recording Allergies, Restrictions, and Adverse Reactions. You can also Write Allergies in the Discharge Orders For Medications. Either entry is saved in the patient's permanent record in the PEAR.
Chief Complaint/Reason for Admission—Entered at Discharge Summary.
1. Click the entry heading.
2. Record a succinct statement of the chief reason for hospital admission. Type to add to, replace, or delete information in the original entry.
History and Reason For Hospitalization and Significant Findings—Entered at Discharge Summary.
1. Click the entry heading. For entries that don't fit in the field display, scroll up or down to view more.
2. Type to add to, replace, or delete information in the original entry.
Venous Thromboembolism (VTE) Management—Required for patients with one or more of the following principal or associated diagnoses recorded in the discharge orders for the visit: deep vein thrombosis (DVT), pulmonary embolism, thrombosis, phlebitis, antepartum DVT, postoperative DVT, DVT of lower or upper extremity, thrombosis of arteries of lower extremity, postpartum deep phlebothrombosis
1. Click the entry heading.
2. If known, click the option to indicate whether the VTE diagnosis was confirmed prior to or during the admission. Otherwise, click to select Unknown.
3. If the VTE diagnosis was confirmed during the admission, document what study or test was used to confirm the VTE diagnosis:
- Click to select from available reports from cardiology and radiology. To view details of a report, click the name of the report.
- Document the test or report manually by typing a description, selecting the date, and typing the time.
- If report information is unavailable, click to select the Unknown option.
See also: Completing the Face Sheet
Admission Labs and Other Studies—From the CDR. Optional for the Summary.
1. Click the entry heading.
2. Check off the labs to include in the Discharge Summary:
- To select an individual lab result, click its place in the grid. Click again to uncheck.
- To select all critical or abnormal values listed (red text), click Select Abnormal.
- To uncheck all previous selections in the section, click Clear All.
- To select all of the tests in a panel, click the panel name. To add the panel name to the summary, click its checkbox. Click again to uncheck.
1. Include report information as needed:
- To view or copy the content of a report, click . Click Close Report Detail to hide.
- To copy the content from a report into the summary, click and drag the text into the corresponding field beneath the report name.
- To copy impressions only for chest view, colonoscopy, endoscopy and vascular reports, click Quick Paste Impressions.
- To append information to the summary regarding a particular report, type in the corresponding field beneath the report name.
- The checkbox for a report is checked automatically when you copy or type text into the comment field. The name of the study of exam and its order date is added automatically to the summary. Unchecking a report removes it from the summary.
- Data limit warnings—If the character count of the field indicates a length of more than 15 lines, the background of the field turns yellow. Field length greater than 21 lines turns the field red. For more information, click or hold the mouse pointer over the information icon in the upper right of the field. Clicking the icon triggers a popup message; click OK to return to the summary. Consider deleting all but the information that is relevant to the discharge. Very large discharge summaries cannot transfer to the SoftMed discharge summary repository or the CDR (Clinical Data Repository). You will not be able to successfully sign a discharge summary with too much data.
1. Click Done.
Hospital Course and Treatment—Required for the summary.
1. Click the entry heading. For entries that don't fit in the field display, scroll up or down to view more.
2. Type to add to, replace, or delete information in the original entry.
Hospital Course and Treatment also accommodates Smartphrases for some conditions. Typing a Smartphrase and pressing ENTER automatically inserts text that serves as guidelines for describing treatments and outcomes for the selected condition.

DEx supports the following Smartphrases for Hospital Course and Treatment:
- .esld = End-Stage Liver Disease
- .ethowd = Ethanol Withdrawal
- .pulmemb = Pulmonary Embolism
- .sepsis = Sepsis
- .syncope = Syncope
If you can't recall the Smartphrase you want, click the Show Help link, then hold the mouse pointer over the icon to display a list of Smartphrases and their related conditions.

The guidelines generated by entering a Smartphrase are tailored to the condition, and include information such as relevant history, evaluations, tests and screenings, medications, consults, and plans for follow-up. You can then edit the entry to complete the picture.
Stroke Specific Care—Required for patients with one of the following principal diagnoses recorded in the discharge orders for the visit: ischemic stroke, paralytic stroke, embolitic stroke, cerebrovascular accident (CVA) , CVA due to cerebral artery occlusion, lacunar infarction, hemorrhagic cerebral infarction
1. Click the entry heading.
2. Click to select an option to indicate whether the patient was admitted for ischemic (IS) or hemorrhagic (IS, IS with hemorrhagic transformation, SAH, ICH) stroke. If Yes, provide the remaining information as prompted:
1. Click an option to indicate if VTE prophylaxis was implemented—if yes, select the type: mechanical, pharmacological, or both.
2. Click an option to indicate whether the patient was evaluated for post-acute care by one or more of the following services: physical therapy, occupational therapy, speech language pathology, or rehabilitation. If not, select the option that describes the reason(s) why.
3. If known, select the date and type the time that the patient was last known to be well or at a pre-stroke baseline. Otherwise, click to select the Unknown option.
4. Click to select Yes if neurological symptoms were first discovered at the same time the patient was last known to be well. If not, click to select No, then select the date and type the time that neurological symptoms were first discovered.
5. If known, select the date and type the time that the initial head CT was performed at MGH. If no CT was completed, click the option for Procedure not performed. Otherwise, click to select the Unknown if procedure performed option.
6. If intravenous tPA therapy was started, click the Yes option, then known, select the date and type the time that therapy began. If not administered during the visit, click the option for tPA not administered with the applicable reason. For the Other option, type a description.
7. If antiplatelet therapy was initiated by the end of hospital day 2, click the Yes option. If not, click to select the No option that describes the reason. For Other, type a description.
8. Click an option to indicate whether the patient has a history or was diagnosed during the admission with paroxysmal, persistent, or permanent atrial fibrillation, or with atrial flutter. Click Unknown if appropriate.
The final section displays data from the discharge orders for the visit regarding orders for antithrombotic and statin medications. Orders that were written for discharge are listed in the Discharge Medications section; the prescription is also listed if one was written.

See also: Completing the Face Sheet
Primary Disease—For liver transplant summary only.
1. Click the entry heading. For entries that don't fit in the field display, scroll up or down to view more.
2. Type a description of the primary disease leading to the transplant. For HCV, include the most recent titer; for HBV, include items for follow-up; for HCC, include native liver pathology.
Type of Graft—For liver, renal, heart or lung transplant summary only.
1. Click the entry heading.
2. When applicable, click to select one donor type: Living related, Living unrelated, or Standard deceased. Click Clear if you make a selection when none apply.
3. When applicable, click to check one or more options: Extended criteria deceased donor, DCD, PHS increased risk donor.
Type of Transplant—For lung transplant summary only.
1. Click the entry heading.
2. Click to select the type: Left lung, Right lung, or Double lung.
3. When applicable, click to check Cardiopulmonary bypass.
Liver Function—For liver summary only.
1. Click the entry heading.
2. Click to select the option to answer: Did this patient need to return to the OR for washout?
3. If Yes:
1. Type the date of the return to the OR.
2. In the Recent Labs and Other Studies section of DEx, include the ultrasound report and any relevant liver, renal, and coagulation results.
Renal Function—For liver and renal transplant summary only.
1. Click the entry heading.
2. If the patient was on dialysis before the transplant, click the Yes option, then type the date of first dialysis or length of time on dialysis. Otherwise, click the No option.
3. If the patient was on dialysis after the transplant, click the Yes option; type the number of dialysis treatments provided in-house, then click (select) and indicate the date of the most recent run. Otherwise, click the No option.
4. If the patient is being discharged on regular dialysis, click the Yes option, then click (select) and indicate the date and type the location for the next expected dialysis. Otherwise, click to select PRN (as needed) or No, as applicable.
Heart Function—For heart transplant summary only.
1. Click the entry heading.
2. Click (select) and indicate the date of the patient's most recent echocardiogram.
3. Type or copy and paste from another source to describe the results of the most recent echocardiogram.
4. If needed,type or copy and paste from another source to provide additional details of the most recent echocardiogram.
5. Click (select) and indicate the date of the patient's most recent heart biopsy.
6. Click (select) and indicate the date of the patient's next anticipated heart biopsy.
7. If needed, type or copy and paste from another source to provide additional details of the next anticipated heart biopsy.
Lung Function—For lung transplant summary only.
1. Click the entry heading.
2. If the patient returned to the OR, click the yes option, then click (select) and indicate the date. Otherwise, click the no option.
3. Click (select) and indicate the date of the patient's most recent CT.
4. Type or copy and paste from another source to describe the results of the most recent CT.
5. Click (select) and indicate the date of the patient's most recent VQ scan.
6. Type or copy and paste from another source to describe the results of the most recent VQ scan.
7. Click (select) and indicate the date of the patient's most recent pulmonary function studies.
8. Type or copy and paste from another source to describe the results of the most recent pulmonary function studies.
9. Click (select) and indicate the date of the patient's most recently completed surveillance bronchoscopy/tbbx (transbronchial lung biopsy).
10. Type or copy and paste from another source to describe the results of the most recently completed surveillance bronchoscopy/tbbx (transbronchial lung biopsy).
11. Click (select) and indicate the date of the patient's next anticipated surveillance bronchoscopy/tbbx (transbronchial lung biopsy).
12. If needed, type or copy and paste from another source to provide additional details of the most next anticipated surveillance bronchoscopy/tbbx (transbronchial lung biopsy).
Wound Care—For heart or lung transplant summary only.
1. Click the entry heading.
2. Click to select the location of the wound from the associated drop-down list.
3. Click (select) and indicate the date of the patient's follow-up visit.
4. Type or copy and paste from another source to identify the provider or service that will be responsible for wound care; include a description of the plan for wound care.
Vascular Concerns—For liver, lung, or heart transplant summary only.
1. Click the entry heading.
2. Click the Yes option of the patient has vascular concerns such as hepatic artery (HA) thrombosis, then type a description in the comments section. Otherwise, click the No option.
Biliary Concerns—For liver transplant summary only.
1. Click the entry heading.
2. Click the Yes option if there are issues with the bile ducts, including placement of a T-tube in the OR. Click No if there are no biliary concerns as described.
3. If Yes, type a description in the Comments; note whether the T-tube was capped on discharge. In addition, in the Recent Labs and Other Studies section of DEx, include any recent report from ERCP (endoscopic retrograde cholangiopancreatography) when available.
Stent—For liver and renal transplant summary only.
1. Click the entry heading.
2. Click the Yes option if the patient has a stent from this procedure; otherwise, click the No option.
3. If Yes, type the date or time frame for removal. Please do not reference other documentation for these plans.
Drain—For liver and renal transplant summary only.
1. Click the entry heading.
2. Click the Yes option if the patient has a drain from this procedure; otherwise, click the No option.
3. If Yes, type the date or time frame for removal. Please do not reference other documentation for these plans.
Episodes of Rejection—For liver or renal transplant summary only.
1. Click the entry heading.
2. Click the Yes option if the patient has a had one or more episodes of transplant rejection; otherwise, click the No option.
3. If Yes, type a description in the Comments section. In the Recent Labs and Other Studies section of DEx, include the biopsy report.
Ischemic Time—For lung transplant summary only.
1. Click the entry heading.
2. Type the time in minutes for each lung.
Acute Graft Dysfunction—For lung transplant summary only.
1. Click the entry heading.
2. Click the Yes option if the patient experienced any injury to the transplanted lung within 72 hours of surgery; otherwise, click the No option.
3. If Yes, type a description in the Comments section.
ECMO—For lung transplant summary only.
1. Click the entry heading.
2. Click the Yes option if the patient had ECMO; otherwise, click the No option.
3. If Yes, click to indicate which system the blood was returned to: arterial (V/A) or venous (V/V). Click to check Preop if applicable.
Ventilator Time—For lung transplant summary only.
1. Click the entry heading.
2. Type the number of days the patient needed mechanical ventilation.
3. Click an option to indicate if the patient needed to be re-intubated.
Length of Stay (post-transplant)—For lung transplant summary only.
1. Click the entry heading.
2. Type the number of days the patient was treated in intensive care after the transplant surgery.
3. Type the number of days the patient was treated on a non-ICU general care unit after the transplant surgery.
Episodes of Rejection—For lung transplant summary only.
1. Click the entry heading.
2. If the patient has had a biopsy:
1. Click (select) and indicate the date.
2. Type or copy and paste from another source to describe the results of the biopsy.
3. Type or copy and paste from another source to describe how the episodes of rejection were treated.
Immunosuppressive Medications Comment—For liver, renal, lung, or heart transplant summary only.
1. Click the entry heading.
2. Type to describe the inpatient course of treatment or future plans for immunosuppressants, including tapering steroid dosing, and goals for therapeutic drug levels of medications such as tacrolimus or cyclosporines.
ID and Prophylaxis—For liver, renal, lung, or heart transplant summary only.
1. Click the entry heading.
2. Type a description of the preventive infectious disease plan in the Prophylaxis section.
3. In the Serology sections for both the donor and patient recipient, click the Positive or Negative option to indicate the donor status for viral infection.
4. Click to select the Yes option if the patient acquired an infection during hospitalization.
1. Click to select one or more checkboxes to indicate the site or agent; for Other, type a description.
2. Click the Yes option if the patient needs antimicrobial treatment on discharge.
3. Click to select Yes or No for both the IV and PO administration routes.
4. Click (select) and indicate the date of antimicrobial completion.
5. Click (select) and indicate the date of line removal if antimicrobial is given IV.
6. Type a description of any follow-up tests or studies planned, including dates when determined.
1. Click the Yes option if the donor was flagged as high risk.
1. Click Yes or No to indicate whether the patient needs follow-up lab testing at one (1) and three (3) months.
2. Click Yes or No to indicate whether a transplant infectious disease (ID) follow-up is needed, then type the date or time frame for the follow-up.
Multidisciplinary plan—For liver, renal, lung, or heart transplant summary only.

To comply with standards set by the Centers for Medicare & Medicaid Services (CMS) for approval of hospital transplant programs, the transplant center must identify a multidisciplinary transplant team and describe the responsibilities of each member of the team. The team must be composed of individuals with the appropriate qualifications, training, and experience in the relevant areas of medicine, nursing, nutrition, social services, transplant coordination, and pharmacology.

This information is included automatically based on the type of summary.
Care Team/Acute Care Plan—For liver, renal, lung, or heart transplant summary only.
To comply with standards set by the Centers for Medicare & Medicaid Services (CMS) for approval of hospital transplant programs, the transplant center must identify a multidisciplinary transplant team and describe the responsibilities of each member of the team. The team must be composed of individuals with the appropriate qualifications, training, and experience in the relevant areas of medicine, nursing, nutrition, social services, transplant coordination, and pharmacology.

This information is included automatically based on the type of summary.
Clinical Visit Date—For liver, renal, lung, or heart transplant summary only.
1. Click the entry heading.
2. Click (select) and indicate the date the patient is scheduled to visit the ambulatory clinic.
Most Recent Labs and Other Studies—From the CDR. Optional for the Summary.
1. Click the entry heading.
2. Check off the labs to include in the Discharge Summary:
- To select an individual lab result, click its place in the grid. Click again to uncheck.
- To select all critical or abnormal values listed (red text), click Select Abnormal.
- To uncheck all previous selections in the section, click Clear All.
- To select all of the tests in a panel, click the panel name. To add the panel name to the summary, click its checkbox. Click again to uncheck.
1. Include report information as needed:
- To view or copy the content of a report, click . Click Close Report Detail to hide.
- To copy the content from a report into the summary, click and drag the text into the corresponding field beneath the report name.
- To copy impressions only for chest view, colonoscopy, endoscopy and vascular reports, click Quick Paste Impressions.
- To append information to the summary regarding a particular report, type in the corresponding field beneath the report name.
- The checkbox for a report is checked automatically when you copy or type text into the comment field. The name of the study of exam and its order date is added automatically to the summary. Unchecking a report removes it from the summary.
- Data limit warnings—If the character count of the field indicates a length of more than 15 lines, the background of the field turns yellow. Field length greater than 21 lines turns the field red. For more information, click or hold the mouse pointer over the information icon in the upper right of the field. Clicking the icon triggers a popup message; click OK to return to the summary. Consider deleting all but the information that is relevant to the discharge. Very large discharge summaries cannot transfer to the SoftMed discharge summary repository or the CDR (Clinical Data Repository). You will not be able to successfully sign a discharge summary with too much data.
1. When any of the results or reports require follow-up, the Recent Labs should be annotated:
- Click the icon to the right of a lab result or report date to open the text entry field for that specific item.
- Type information for follow-up, then click Save.
1. Click Done.
- The result or report name and date are stored with your input in the section below, Items for Follow-Up/Annotations.
- Update annotations by clicking in either the Most Recent Labs and Other Studies or the Items for Follow-Up/Annotations sections.
Items for Follow-Up/Annotations—Entered at Discharge Summary.
- Numeric pending lab tests are listed automatically in this section. To include all other pertinent results or studies from pathology, radiology, microbiology, etc., annotate manually (see next).
- Specific results or reports that require follow-up can be annotated in the Recent Labs section:
1. Click the link to open the section for Most Recent Labs and Other Studies.
2. Click the icon to the right of a lab result or report date to open the text entry field for that specific item.
3. Type information for follow-up, then click Save.
The result or report name and date are stored with your input in the section below, Items for Follow-Up/Annotations.
- View details of the annotations for results and reports by clicking in the Items for Follow-Up/Annotations section.
- Update annotations by clicking for the result or report in either the Most Recent Labs and Other Studies or the Items for Follow-Up/Annotations sections.
- To erase the note, click Remove in the Items for Follow-Up/Annotations section.
- Other items that require follow-up should be listed in the Items for Follow-Up:
1. Click the link to open the section for Items For Follow-Up/Annotations.
2. Type a description in the field for Other Items Requiring Follow-Up.
- When pending labs have been added automatically to this Follow-Up/Annotations section, the Yes option is selected by default to answer the Provider Note question "To your knowledge, does the patient have pending labs or studies that will require follow-up?"
- If no pending labs have been listed automatically, and you do not know of any pending studies or reports, click the No option in the Provider Note section.
- If the you do know that there are pending studies or reports:
1. Click the Yes option in the Provider Note section.
2. Annotate any relevant labs or studies in the Recent Labs section to include them in the list of Items for Follow-Up/Annotation (see instructions above).
3. For other tests or studies, type a description in the field for Other Items Requiring Follow-Up.
- When the Yes option is selected, the Discharge Summary printout includes information on obtaining results from Health Information Services.
Discharge Communication—Entered at Discharge Summary.
1. Click the link to open the section for Discharge Communication.
2. Click to select an option, Yes or No, to document that a warm handoff took place within 24 hours of discharge.
3. To remove the selection, click Clear.
Warm handoffs are direct clinician-to-clinician communications that take place around the time of hospital discharge. A warm handoff can be a focused verbal or electronic (e.g. email) communication between an inpatient and outpatient provider (PCP or specialist), or a nurse-to-nurse verbal communication.
Breastfeeding (OB summary only)—Entered at Discharge Summary.
1. Click the entry heading.
2. Click to select an option—Yes, No, or Unknown.
Condition At Discharge—Entered at Discharge Summary.
1. Click the entry heading.
2. Click to select an option. For Other, type a description in the field provided, then click Done.
Selecting the Other option and leaving the field blank clears the Discharge Condition.
Discharge Medications (including Prescription information when applicable—Required; pulled from the discharge orders.
- To write orders for medications at discharge (including take-home prescriptions):
1. Click Orders in the CAS to access Order Entry.
2. See Ordering Discharge Medications.
- To enter manually:
1. Override the/Discharge Orders Lock.
2. Click the entry heading. For entries that don't fit in the field display, scroll up or down to view more.
3. Type descriptions of each for all medication orders; include the medication name, administration route, dose and dosing units, frequency, and if applicable PRN with reason(s), start date and time, duration, reasons to hold administration, instructions, and date and time of last dose.
- If flagged with , see Updating DEx with the current Discharge Orders information
Vaccinations—Required; orders from Order Entry only, administration information from the eMAR (electronic medication administration record).
- To write orders for medications at discharge (including take-home prescriptions):
1. Click Orders in the CAS to access Order Entry.
2. See Ordering Discharge Medications.
- To write orders for vaccinations in-house:
1. Click Orders in the CAS to access Order Entry.
2. See Ordering Medications.
- See also Standing Orders for Required Vaccinations
- To enter manually:
1. Override the/Discharge Orders Lock.
2. Click the entry heading. For entries that don't fit in the field display, scroll up or down to view more.
3. Type descriptions of each for all vaccinations ordered in-house or on discharge; include the vaccine name, administration route, dose and dosing units, frequency for multi-dose vaccines, and if applicable PRN with reason(s), start date and time, duration, reasons to hold administration, instructions, and date and time of last dose.
- If flagged with , see Updating DEx with the current Discharge Orders information
Discharge Instructions and Plans For Follow-Ups—Required; pulled from the discharge orders for Diet, Activity, Treatment, Nursing Instructions, Equipment, and Follow-Up Appointments. Includes follow-up for core measure monitoring of heart failure and chronic obstructive pulmonary disease (COPD). View only in DEx until the Discharge Order is signed. Updates made in DEx are not saved back to the Discharge Order.
- To update the Discharge Instructions and Plans For Follow-Up in Order Entry:
1. Click Orders in the CAS to access Order Entry.
2. See Adding Information on Diet, Activity,Treatment, patient Instructions, Equipment, Follow-Up to Discharge Orders.
- To enter manually:
1. Override the/Discharge Orders Lock.
2. Click the entry heading. For entries that don't fit in the field display, scroll up or down to view more.
3. Type descriptions of each for all of the following discharge orders when applicable:
- Diet
- Activity
- Treatment
- Nursing Instructions
- Follow-Up Appointments
- Follow-up for core measure monitoring of heart failure and chronic obstructive pulmonary disease (COPD)
- If flagged with , see Updating DEx with the current Discharge Orders information.

Post-Discharge Goals/Care Plan—Required; pulled from the discharge orders.
- To write orders for medications at discharge (including take-home prescriptions):
1. Click Orders in the CAS to access Order Entry.
2. See Completing the Multidisciplinary Care Plan for Discharge.
- To enter manually:
1. Override the/Discharge Orders Lock.
2. Click the entry heading. For entries that don't fit in the field display, scroll up or down to view more.
3. Type descriptions of each post discharge goal and the multidisciplinary plan to accomplish that goal. "Continuity of Care" is the default in the discharge order, with the instruction to "Please attend all post-discharge appointments."
- If flagged with , see Updating DEx with the current Discharge Orders information
Last Attending Physician of Record—Automatically drawn from the patient's care team information. If needed, you can click the heading and look up a different provider to correct this.
- To update the name:
1. Click the entry heading.
2. Click the corresponding to remove the name.
3. Type the last name of the MD in the Last Attending lookup field.
4. Click or press ENTER.
5. Providers who match your entry are listed. Click the appropriate name. Your selection is displayed to the right of the lookup.
Provider to Contact Regarding Hospital Stay—From Order Entry, Face Sheet. Allows update using the MGH Provider List.
- To update the name:
1. Click the entry heading.
2. Click the corresponding to remove the name.
3. Type the last name of the provider in the Provider to Contact lookup field.
4. Click or press ENTER.
5. Providers who match your entry are listed. Click the appropriate name. Your selection is displayed to the right of the lookup.
Copies to (CC:)—Identification of any providers who should receive a copy of the Discharge Summary. Primary care provider (PCP) and referring MD are listed automatically if possible. Allows lookup of contact information available in the MGH Provider List.
- To list one or more recipients:
1. Click the entry heading.
2. Type the last name of the MD in the Copies To (CC:) lookup field.
3. Click or press ENTER.
4. Providers who match your entry are listed. Click the appropriate name. Your selection is displayed to the right of the lookup.
- To remove a name:
1. Click the entry heading.
2. Click the corresponding .
Additional CC—Contact information for recipients not listed as MGH Providers.
1. Click the entry heading.
2. Type the name and contact information for any recipients who are not listed in the CC lookup.