Contents
Document Discharge Note Using the Discharge Form
Background
When the client's care team has made the decision to discharge the client, there are several steps to consider as discussed below.
Note: Profile EMR workflows are determined by your site leadership, therefore forms/templates reviewed below may not be reflected in your EMR workflows.
Review Medical Record
Review each segment of the Medical Record window for outstanding items relevant to your EMR-workflow, such as:
- Unresolved encounters (i.e. outstanding documentation)
- Pending tasks
- Unsigned transactions
- Add or inactivate problems as required per clinic policy (e.g., SHx113 Lost to Follow Up)
- Open intervention sets and recalls
- Incomplete clinical care plan
- Parked forms
- Open inward or outward referrals
Review Alter Client Window
Review the Alter Client Window for outstanding items such as:
- Future appointments
- Admin alerts that are clinic-specific (under NOTES tab)
- Unprocessed billing claims or reconciliations
- On wait list
Document Discharge Note Using the Discharge Form
To document a Discharge Note and/or complete the Discharge Form, create a New Encounter and enter dcn\. The dcn\ typing template will title the encounter contact as 'Discharge Note' and will also open the 'Discharge Form'. The Discharged From field will automatically populate to the POS of the currently logged in user.
The Discharge Form is available for use by any POS.
*NOTE: Some teams have their own distinct Discharge Note typing templates, therefore staff should always refer to their Program/Site specific discharge workflows for guidance around which forms/typing templates should be used.
Update Care Team
Update Care Team information by removing your clinic and care team from the Client Info Panel (Yellow Bar). The exception would be in the event of client death (i.e. PC/ALT POS and MRP remain attached to the client record). Consider the following fields:
- PC POS
- Alt POS
- MRP
- Alt Provider
- Care Team
Client Record Inactivation
Per Standard Operating Procedure, only inactivate a client if no other clinic is involved in the client’s care where:
- PC POS, MRP, Alt POS, and Alt Prov fields are empty
- There are no tasks, appointments, interventions, referrals, or recalls outstanding for other clinics
Note: A warning will appear on inactivation if any of the above items exist
Stored Query
Use of the Discharge Form enables POSs to use the 'Clients Discharged by POS and Date Range' stored query to review a list of clients discharged from the POS for a specified date range.
Location: Operational Reports - Clinical
Name: Clients Discharged by POS and Date Range
Comments: The report may show short code ID displayed under Reason and Destination columns. Please disregard the Reason and Destination codes—they are for system reference only.
Resources
Profile EMR Admin Checklist
Standard Operating Procedure: Primary Care Place of Service and Alternate Place of Service
Document Client Death in Profile EMR
Client Info Panel (Yellow Bar)
Typing Templates- Detailed