The Discharge Summary is the most important document created during the hospital stay.  With it, a continuity of care can be established which leads to excellent outcomes and which minimizes errors; without it, there is no effective communication from inpatient to outpatient. 

For the Discharge Summary to work properly, the following steps must take place before opening the Master Discharge Template:

1.  Open a visit for the date of discharge

If you complete your discharge summary on the day you discharge the patient from the hospital, as you should, you do this simply by clicking on NEW on the Main Tool Bar.

If you are completing a delinquent discharge summary, you must create a Custom Visit so that the Discharge Summary is filed on the date of discharge, even though it has been created on a different date. 

You do this by going to the Left Top of the screen and clicking on FILE.   You then click on NEW and then on CUSTOM VISIT. 
                       

At this point, a Pop Up entitled Custom Visit comes up. 

Beside the date on this Pop up, there is a Button with three dots on it.  If you click on that button, a calendar comes up which allows you to change the date to the date of the patient’s actual discharge.  Once the date is correct, you click the OK button to the right top of the Pop Up.  This creates a visit with the correct date.

2.   At this point, your New Visit has nothing in it.  In order to make the Master Discharge Summary work, you must follow these steps:

      At the bottom of the Main Tool Bar, you will click on the top left icon which is the Template Icon.  You will then select Master GP. 

Double click on Master GP, or highlight it and the click on the OK button at the bottom of the Pop Up.

On the Top Tool Bar, the second icon is SAVE.  You will click on this icon to save your change.

You will notice that Master GP now appears below the date of your custom visit, or your new visit at the right of your screen on the Main Tool Bar.

3.   At this point, you will go back to the patient’s date of admission and find the Assessment under the date of admission. 

You will highlight Assessment by clicking on it.  You will then hold the left mouse key down and DRAG the assessment up to your current visit – either a new visit if you are doing the discharge summary on time, or a custom visit if you are completing a delinquent discharge summary.

Once you have successfully dropped this assessment on the date of the new visit or the custom visit, a pop up will appear which asks you if you want to COPY and SAVE the assessment to this visit.  You click yes.

You will notice now that your new or custom visit has both the Master GP and the Assessment listed under it.

 At this point, go back to the Main Tool Bar and click on the top left hand icon for
Templates.  You will select the Master Discharge Summary one of three ways:

You can return to AAA Home and select it.

 If the Master Discharge Summary has been placed in your preferences list, as the Master GP has, you will simply double click on Master Discharge Summary.

NOTE: For more on how to set up your preferences, Click Here

If it has not, you will check the box at the bottom of the Template Pop-up which says ALL.  You will then go down to Master Discharge Summary and click on Master Discharge Summary.

As the Master Discharge Summary is first accessed, a pop up will display to allow you to select a hospital location.

You will notice that the Master Discharge Summary shows the admission diagnoses and the discharge diagnoses. 

You can change the Discharge Diagnoses and/or their status, but the admission diagnoses do not change.  However, if you do not go through the steps above, this functionality will not work properly. 

At this point, you should close the main tool bar and complete the Discharge Summary using the Navigation buttons on the Master Discharge Summary Template.

The Master Discharge Summary Template has the following functions:

• Admission Date -- this date must be manually entered into the template.  It is imperative that the dates be correct on the discharge summary.
• Discharge Date – this date must be manually entered into the template.  It is imperative that the dates be correct on the discharge summary.

Down the left hand column are listed the Admitting Diagnoses and the patient chronic conditions.  These cannot be changed on the discharge summary.

Next to this are the Discharge Diagnoses and the patient’s chronic conditions.  These can be changed, and should be changed to update the patient’s record.  In this way, the admission diagnoses will reflect the clinician’s impression on admission and the discharge diagnoses will reflect the clinician’s conclusions after the patient’s hospital evaluation and treatment are complete.

The Column next to the discharge diagnose has four parts:

• Discharge Condition – there is a pop-up with the options:  deceased or stable.
• Discharge Prognosis – there is a pop-up with the options:  Good, Poor, and Terminal.
• Discharge Time

On the right hand side, there are 15 navigation buttons on the Master Discharge Template.

Six of the first seven buttons launched templates which are identical to templates on the Master GP Templates, they are:

• Histories
• Health
• System Review
• Physical Exam
• Radiology
• EKG

The fifth button entitled Procedures launches a template which enables the  documentation of the procedures and studies done in the hospital.

At the top of this template which is entitled Special Procedures are six buttons, which launch pop-ups with which to document special studies:

Cartotid Doppler

Colonoscopy

Echocardiogram

Modified Barium Swallow

Venous Doppler

VQ Scan

Following this there are a number of boxes for the documentation in free text of the results of

• Bronchoscopy
• CABG
• Cardiac Cath
• Cysto
• EGD
• Surgical
• Echo
• MRI
• Doppler
• Ultrasound

Laboratory Navigation Button

This allows the documentation of:

• Arterial Blood Gases
• CBC
• CMP
• CPK/Troponins
• Cultures
• Drug Levels
• UA
• PT/INR
• Other

The next two navigation buttons are:

• Hydration  -- for instructions on using this template see this LINK
• Nutrition – for instructions on using this template see this LINK

The next Navigation button is Hospital Course

This allows for detail to be given about the patient’s hospital course and condition on discharge.

Nursing Home Navigation Button

This opens a template which allows for specific instructions to be given for a patient who is being transferred back to the nursing home.

Follow-up Instructions Template

This is a list of instructions to the nursing home or family about follow-up.  If the patient is going home the Standard Home Discharge Order buttons should be activated:

If the patient is going to the Nursing Home the Standard Nursing Home Discharge Orders should be activated.

In either case, once the default orders are reviewed, other pertinent issues like “when to stop antibiotics,” “when sutures are to be removed,” etc., should be activated.

Follow-up LOC Template

This launches a template with the names, addresses and telephone contact information for a number of clinics which are able to care for patients without insurance.

Document – this creates the Master Discharge Summary document for placing on the chart and for sending to the Nursing Home with the patient.