Overview of Discharge Orders, Instructions, and Patient Care Referrals

 

Uses—Discharge orders and Patient Care Referrals are not used for wellborn nursery discharges. Face sheet discharge orders are used for all other patients (including maternity, beginning 9/10/2008). See Writing Nursery Discharge Orders.

Completing forms in advance—Discharge orders and Patient Care Referrals can be written from the date of admission and saved as preliminary until the patient is ready for discharge. The forms can be updated and saved as preliminary as many times as needed during the visit. Discharge orders must be signed when a new discharge medication is added, before printing forms or medication prescriptions when there have been changes, and before switching to the PAML builder (pre-admission medication list) or PDML (patient discharge medication list) when changes have been made. In these cases, you are prompted for your clinical key signature only. The status of the orders, preliminary or final, is not affected. See Writing Discharge Orders and Instructions.

Making changes to the forms—Discharge forms in progress can be edited by any provider with the appropriate authorization. To find out who made the most recent changes to any field on the forms, click the field while watching the bottom left corner of the form.

Access to forms—If a folder is blue, you have authorization to enter information in the corresponding form; you can only view information in the yellow folders. When you call the Face Sheet/Discharge function, it will open to the appropriate form automatically. See below for more information.

MDs, PAs, NPs, and CNMs  can complete the Face Sheet, Medications, Order Information, and Services forms to discharge a patient. RNs can fill out these forms, but they must be signed by an MD, Physician Assistant, or Nurse Practitioner. Reimbursement by Medicare depends on this sign off of the Face Sheet and Medications forms. Medication prescriptions for the patient to take home must be signed on paper by an MD. For Patient Care Referrals, an MD, PA, or NP must sign the Certification following the patient demographics "three-page" form. RNs can fill out the referral, and also check off a flag in the Nursing Discharge Notes that will remind the MD that a Patient Care Referral is needed. MDs have view-only access to the nursing forms. See Writing Discharge Orders and Instructions.

RNs and NPs can write, edit, and sign off Nursing Discharge Notes, the Post Hospital Patient Care Plan, the nursing Medications form, and the Case Management form. The Nursing Discharge Notes include an option to remind the MD when a Patient Care Referral is needed. An RN, along with the patient or an authorized representative, must sign the paper printout of the Post Hospital Patient Care Plan. RNs and NPs can also fill out the Hospital Care Provider, Post Hospital Care Provider, and Follow-Up Appointments forms. RNs can complete the Face Sheet, Medications, Order Information, Services, and Patient Care Referral forms, but an MD, Physician Assistant, Nurse Practitioner, or Certified Nurse Midwife must cosign these verbal orders. See Writing Discharge Orders and Instructions.

Medical Students can complete any of the face sheet discharge orders, patient care referrals, and follow-up appointments forms. As with all med student orders, these are inactive until cosigned by an authorized clinician. Med students have view-only access to the nursing forms. See Writing Discharge Orders and Instructions.

Patient Care Services clinicians including Physical Therapy, Occupational Therapy, Nutrition, Speech Language Pathology, Social Services, and Spiritual Care (Chaplaincy) can view any of the discharge and referral forms. Each specialty is authorized to write and edit the discharge instructions for that specialty, as well as the Hospital Care Provider, Post Hospital Care Provider, and Follow-Up Appointments forms. See Writing Discharge Orders and Instructions.

OAs can view any of the discharge and referral forms. In addition, OAs are authorized to write and edit the Follow-Up Appointments forms. See Writing Discharge Orders and Instructions.

Finalizing discharge orders—Discharge orders can be saved as final whenever the patient is ready to go. Discharge orders cannot be saved as final more than three (3) days before the discharge date on the Face Sheet. The discharge date also cannot be more than three (3) days in the past. See Completing the Face Sheet. The system checks automatically for required entries. Each medication on the pre-admission medication list (PAML) and each active inpatient medication is reconciled using the Discharge medication comparison list. See Reconciling Medications at Discharge for more information, demonstrations, and procedures.

When signed as final by an MD, Nurse Practitioner, Physician Assistant, or Certified Nurse Midwife, the patient's Order Status in the UCM includes the Discharge and Pending flags, and the discharge order is listed in the active orders view. Both flags are cleared when the orders are signed off for RN review and transcription.

Finalizing discharge instructions—Discharge instructions can be completed and signed by an RN or NP at any time. These are finalized if signed with the option indicating that the patient is ready for discharge. The signature is separate from the signature for discharge orders. Final signature of the discharge instructions does not generate a flag in the patient's order status in the UCM; they do not require RN review and transcription, as they are generated by nursing in the first place. The discharge instructions are listed in the patient's active order view when finalized. See Signing Discharge Orders.

Updating finalized discharge orders—Once Discharge Orders are finalized, changes can be made by any authorized user until the patient is discharged from the PATCOM system. However, if an RN or medical student makes these changes, the orders must be re-signed by an MD, NP, PA, or CNM. Printing is unavailable until the orders are re-signed. The Discharge and Referral forms are available for amendment by an MD, NP, PA, or CNM up to 36 hours after the patient has been discharged from the PATCOM system. Such amendments create a Medical Record Addendum.

Viewing Discharge Information—The face sheet and discharge orders, discharge instructions, and DEx discharge summary are all available for viewing, copying, and printing from the reports section of the Results Viewer. See Reports in the Results Viewer.

Printing—Forms can be printed at any time, although the face sheet, patient care referral, nursing discharge note, and post-hospital care plan cannot be printed until signed as final. Copies are not official—and are marked as such—until the orders and instructions are signed as final. The print function for each selected form will generate the correct number of copies for appropriate filing and distribution. See Printing Discharge Orders, Forms, and Instructions.

Much of the information included in a patient's online face sheet, discharge orders, and discharge instructions is included in the printout of the Post-Hospital Patient Care Plan (PHPCP). The PHPCP is printed, reviewed with the patient, family, and/or caregiver, and sent with the patient at discharge. To help clinicians recall what will be seen by the patient, each field with information entered that prints on the 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.

Patient and family education—Materials can be accessed and printed by clicking the Patient/Family Education folder. This opens the MGH Patient and Family Education and Resources page.

Discharge Medications List—When available for the selected patient's care unit, the Patient Discharge Medication List (PDML) is generated automatically. See Overview of the PDML. 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).

Medication prescriptions—Providers can write a prescription as needed for any medication ordered for discharge. See Completing the Prescription for a Discharge Medication. The medication prescription can be printed directly to the MGH outpatient pharmacy, or on the medication prescription printer on the care unit (to be given to the patient), or both. See  Printing Medication prescriptions for Discharge.

Discharge summaries—Applicable information in the face sheet and discharge order is copied to a discharge summary for the same admission, in the DEx (Discharge Express) application. DEx is available to authorized clinicians as both a standalone application from the Start > Partners Applications menu, and an application in the CAS. See Writing Discharge Summaries in DEx.

Reports—Discharge Orders and Instructions can be viewed and printed in the Results Viewer in both the Clinical Application Suite (CAS) where MGH Order Entry resides, and in the web Results Viewer, which is available to web LMR users and as a standalone application in the Partners menu. See Discharge Reports in the Results Viewer Help for instructions on accessing these reports.