Nursing Responsibilities—RNs and NPs are responsible for the following documentation for discharge:
Nursing Discharge Notes (Nsg D/C Notes)
Post Hospital Patient Care Plan
Medications (under Discharge Instructions)
Case Management
The Nursing Discharge Notes include an option to remind the discharging clinician when a Patient Care Referral is needed.
In addition, RNs and NPs can also fill out the forms for Hospital Care Provider, Post Acute Hospital Care Provider, and Follow-Up Appointments. RNs can complete the Face Sheet, Medications, Order Information, Services, and Patient Care Referral forms, but an MD, PA, NP, or CNM must cosign these verbal orders.
Nursing medication reconciliation—As part of the medication reconciliation process, RNs review the pre-admission medication list (PAML) with the patient. Before the patient is discharged, the nurse reviews the PAML and the discharge medication orders, then documents the review on the nursing discharge medications form. The RN also prints the patient's discharge medication list (PDML) and reviews it with the patient.
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 the face sheet and 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 Viewing orders.
Discharging the patient—An RN, along with the patient or an authorized representative, must sign the paper printout of the Post Hospital Patient Care Plan. Each patient who is discharged home should be given a copy of their discharge meds list at the time of discharge. When the patient is ready to go home, the RN checks the discharge orders to be sure that the medications have not changed. If there are changes, the nurse prints a new copy of the PDML, and reviews the changes with the patient. The last version printed is saved in both the patient's Discharge Orders in the medical record for the visit, as well as on the Reports tab of the Clinical Data Repository (CDR). See Viewing Reports in Results.
Printing—Forms can be printed at any time. Copies are not official—and are marked as such—until activated. The print function for each selected form will generate the correct number of copies for appropriate filing.
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.
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 as an application in the CAS. MDs, NPs, PAs, and CNMs are authorized to update the discharge summary. RNs can access the OnCall record and DEx discharge summary for viewing.
Instructions:
Overviews: