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Discharge Instructions

Brief Tutorial for Providers

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What?• Electronic Discharge Instructions will replace the

current templated forms at SFGH to provide patients discharged or transferred from SFGH with instructions on their post-discharge care plan.

• It is a multi-disciplinary document with contributions from provider/s, social work/utilization management, and nursing.

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Why?• The new version is meant to provide the patient

with a clear post-discharge plan of care and improve the safety and quality of discharges at SFGH.

• To help the patient understand why he/she was admitted to the hospital and his/her responsibilities in the post-discharge care plan.

• It is required to improve compliance with ACA and Joint Commission guidelines.

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Who?• All patient discharged from a med/surg unit.• This includes patients who are occasionally

discharged from 5E/5R/4E and all patients discharged from 4B step-down and 5D telemetry.

• Med/surg and pediatric patients discharged from 6A.

• Psychiatry, outpatient surgery/PACU, ER, L&D, 6C/6H will not participate in this pathway.

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Where?• LCR will have a new tab on the left column of the

patient’s record titled Discharge Process.

• Under this tab, select the discharge instructions option to enter instructions for the patient.

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When?• Starting Tuesday April 29, 2014 the electronic

version will replace the templated triplicate instructions.

• Discharge instructions can be started prior to the day of discharge and modified by any provider.

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How?• SW/UM will enter any relevant referrals.• The primary provider will complete the required sections

and any other applicable sections.• When the med reconciliation and ePDP are also

complete, the provider will hit MD finalize on the discharge instructions.

• The RN will enter any additional education/teaching performed and print the entire multi-disciplinary document to review with the patient. The discharge instructions will include a medication list. A copy will be given to the patient.

• The discharge instructions with ePDP will ultimately be scanned and uploaded to the LCR in Reports/Notes.

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Example of the new discharge instructions pathway.

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You can review all the discharge instructions

entered by the treatment team by

clicking on the Summary tab.

Providers are responsible for completing the following tabs /

sections.

Social Services and Utilization Management

complete these tabs / sections.

Nurses complete the

NURSING tab.

Complete each of the provider tabs above. Yellow tabs are required for all

patients.

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To Finalize the document (all tabs completed as appropriate)

so the nurse can print and review with the patient, click MD Finalize on the Summary tab. Note: ePDP must also

be complete.

Use the Save button located at the bottom of each tab to save

at any time. You may then continue working on the saved instructions or return at a later

date.

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You can view the instructions that

will be given to the patient by

selecting View Discharge

Instructions.

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Choose “Continue” to make changes.

Go back to Add/Modify Discharge

Instructions to make changes to an already finalized document.

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If you are revising a finalized discharge

summary, click on the section you want to change then click “Modify” or go

directly to the tab you want to modify. When you are done hit Revise MD Final

below

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Example of discharge documents that RN will

print and provide to patient.