Discharge Summaries

Discharge Summaries

Discharge Summaries– Can be challenging

What happens during a hospital course is now more complex and more detailed than in the past, with more data generated in a shorter length of stay

Discharge Summaries

Discharge Summaries– Are a necessary patient safety device– Serve as a vital piece of communication

between the inpatient team and the outpatient primary care physician

Discharge Summaries

Discharge Report

Discharge Report

All sections must be completed– Please remember to select the correct Facility

on the pull down as this influences pharmacy and other issues

– Continuing Patient Care (CPC)/Transfer Form Needed Click Yes If:

– Patient is going to a nursing home– Patient is going to a rehabilitation facility– Patient will be receiving any form of home care

Discharge Report

View/Edit Manual Entry– Capturing Key Elements of the Hospital Course

is critical for proper care following discharge Hospital Course

– Needs to be clear, concise, and organized– Avoid nonstandard abbreviations– Brevity is okay as long as all the appropriate

information is conveyed in an accurate manner

Discharge Summaries (suggested) Hospital Course

– Paragraph 1: Principal Diagnosis– Paragraph 2: Secondary Diagnosis– Paragraph 3: Brief History of Presenting Illness

with pertinent past medical history, family history, and social history with

– Paragraph 4: Presenting Physical examination with Pertinent labs, radiologic findings

– Closing List: numbered problem list with plan for each problem and follow-up

CC List

• Please make sure PCP is selected, this will allow discharge summary to be electronically sent to a HFMG PCP when you submit the discharge

• Recommend cc any additional HFMG specialists who saw the patient inpatient or will be following up as outpatient

CC List Must Include

– Attending physician at time of discharge– Name of intern or resident at time of discharge (if

applicable on a teaching service)– Include PCP if within the Henry Ford Health System– CC To:

Other relevant physicians Anticoagulation Clinic

– Usually automatically selected if enrolled within Henry Ford Dialysis Unit

– Only West Pavilion or other Henry Ford Satellite Dialysis Units

Discharge Medications

Discharge Medications

Discharge Medications Always ask the patient what medications are needed at

discharge– Do not refill and give all medications if they are not needed

Patient wants medications from the discharge pharmacy – Select Rx-Pharmacy-Lobby-HFH

Send medications to the pharmacy Print and sign only controlled substance prescriptions

– Do not forget to include your DEA number– Put on the front of the chart – Discharge pharmacy will collect for their records

Patient wants medication from outside pharmacy– Call pharmacy to talk to the patient first– Select Outside Pharmacy

Print and sign the prescriptions and give to the patient Do not forget to put your DEA number on controlled substance

prescriptions

Diagnoses

Follow-up Appointments

Follow-up Appointments If scheduling follow-up with the patient’s

PCP specify the name of the PCP when calling the discharge line– Check the appointment to ensure the patient is

actually seeing his/her PCP Every patient does not need to be seen by

his/her PCP in one week– The time interval for follow-up depends on the

patient diagnosis and what needs to be followed in the outpatient setting

Submit

When ready to submit your document, type your CarePlus password and click “OK”

Submit

Discharge summaries must be submitted within 24 hours after discharge

Delete Discharge Rarely need to use this option

Vaccinations/Allergies

Patient Instruction

Patient Instruction

Call Physician If:– Please be sure to check the boxes that apply

Patient Education Needs:– Complete the sections as needed based on

each individual patient Patient Educational Material Given:

– It is imperative to check the appropriate boxes (Heart Failure, Acute Myocardial Infarction, Diabetes, Asthma) when applicable

Demographics Physicians do not enter any information in this section

Follow-up Care

Follow-up Care Follow-up care / Other instruction

– Include: Instructions for the home care nurse (what labs to

draw, when to draw next set of labs, who to notify about lab results)

Instructions for the nursing home/rehabilitation facility regarding:

– What labs need to be drawn and when – Anticoagulation if applicable– Special diets and tube feedings if applicable

Home Health Care Services and Equipment Completed by the case manager

Case Manager Completed by the case manager