Discharge Instructions Brief Tutorial for Providers Last updated: 06/18/20141

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. Last updated: 06/18/20142

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. Last updated: 06/18/20143

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. Last updated: 06/18/20144

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. Last updated: 06/18/20145

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. Last updated: 06/18/20146

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. Last updated: 06/18/20147

8 Example of the new discharge instructions pathway.

Last updated: 06/18/20149 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.

Last updated: 06/18/ 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.

Last updated: 06/18/ You can view the instructions that will be given to the patient by selecting View Discharge Instructions.

Choose “Continue” to make changes. Last updated: 06/18/ Go back to Add/Modify Discharge Instructions to make changes to an already finalized document.

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 Last updated: 06/18/201413

Last updated: 06/18/ Example of discharge documents that RN will print and provide to patient.