Background
YICMT NPs who work at Youth Concurrent Disorders Services (YCD) will document their discharge summaries in the Youth Concurrent Disorders Services Discharge Summary form.
Order Discharge Medications
Important! For Discharge Medications to prepopulate in the Discharge Summary form, enter discharge medications on the same day PRIOR to opening the Discharge Summary Form in the following order:
- Non-OAT prescriptions using the Scripts module in New Encounter
- OAT prescriptions using the OUD Form (oud\)
Launch the Discharge Summary Form
Only NPs will document in the YCD Discharge Summary form.
In the New Encounter, click New Problem then enter typing template code to launch form: YCDD\
It will automatically title the Encounter note: Youth Concurrent Disorders Services - Discharge Summary
Tip: The form can also be opened from the New Encounter > Actions Panel: Forms.
Document the Discharge
There are two tabs on this form: Discharge Summary and Discharge Plan. The form defaults the client's name and demographics, discharge date to today (editable), and the logged in user in the Clinician Name field.
Tip: To edit client demographics, see Client Registration Form.
The following fields are populated FROM the last saved Intake Assessment form:
- Admission Date
- Location
- Treatment Plan section (on Tab2)
Discharge Summary (Tab 1)
Discharge Type section
Select the appropriate checkbox to indicate the discharge type:
- Planned Discharge
- Transfer to hospital
- Client-initiated discharge
Discharge Substance Use Care Medications, Dosage and Instructions section
For Discharge Medications to prepopulate in the Discharge Summary form, enter discharge medications on the same day PRIOR to opening the Discharge Summary Form.
Once inserted into the Discharge Summary form, you may edit the freetext field but these changes would not be reflected in the Scripts module nor the previously-created OAT Rx form.
Complications During Treatment Course
Document any complications during the Treatment Course using the checkboxes. Enter any additional comments in the Comments section.
Medical Follow-Up/Discharge Destination
Document the client's discharge destination using the appropriate checkboxes and freetext fields.
Harm Reduction
Document the harm reduction education and tools provided to the client using the appropriate checkboxes and Comment field.
Discharge Plan (Tab 2)
Treatment Plan section
This section is populated from the last saved Intake Assessment form.
Modify the treatment plan as appropriate. Update the comments and add your signature and date/time stamp using s\.
Ongoing Care Plan section
This is a freetext field.
Provider Signature sections
Your digital signature will automatically be populated at the bottom of both tab1 and tab2 (if the digital signature image is available in Profile EMR EMR).
Print, Save, and Close the Discharge Summary Form
After the form is saved and closed, select text from the form is pushed to the encounter note. You can further edit the text in the encounter though these changes would not reflect on the form. The form is saved as a hyperlink in the encounter and can be opened by clicking on the hyperlink or from the Forms segment of the Medical Record.
There are four buttons to save/print the form:
- Print: Clinicians and admin staff may use this button if no modifications are made to the form and only a printed copy is required.
- Print This Page: Clinicians and admin staff use this button to print the current page only
- Print, Save, Close: Clinicians use this button if a printed copy of the Intake Form is required after it is completed.
- Save & Close: Clinicians use this button to save and close the form without printing.
Related Help Files
Youth Concurrent Disorders Services - Intake Assessment Form