How to Discharge
Discharge planning happens continuously throughout a patient’s hospitalization, not just the moment they’re medically ready to leave. You can help ensure your patients have timely post-hospitalization follow up (and that you aren’t scrambling to get things done for them the day they leave!) by staying organized and starting to work on some of these things early. There are a few key components that go into every discharge, which you can keep track of with the mnemonic MISO.
Medications
All discharges should be completed through the Discharge Navigator on Epic.
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Click the Discharge tab in a patient’s chart to enter the Discharge Navigator.
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On the left sidebar, select Order Reconciliation to open the discharge med rec.
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You are now in the discharge orders section, which opens by default on the Reconcile Problem List for Discharge subsection. Since we aren’t using the active problem list that auto populates through Epic for notes, you can move past this to click on the next section, Review Orders for Discharge.
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Review Orders for Discharge is essentially the discharge med rec. You will be able to see all of their home medications as well as anything you’ve started during this hospitalization.
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In order to e-prescribe medications, you will need to link the patient’s pharmacy to their orders. In the lower right hand corner above the “Sign” button, it will either have the name of their pharmacy or “no pharmacy.” Click on this and it will take you to a screen where you can put in the patient’s pharmacy.
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Each home medication has three icons next to the name.
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The green arrow will tell your patient to continue the medication as they were taking it.
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The yellow pencil will open up the order for the medication so you’re able to edit how they are taking it (frequency, dose)
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The red X will tell them to discontinue the medication.
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Each inpatient medication has two icons next to the name
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The green plus sign will add it to your patient’s medication list and allow you to prescribe it
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The red no symbol will discontinue the medication upon discharge.
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You must take an action on each home or inpatient medication to complete this section.
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To refer your patients for follow up appointments, type “Amb Ref [specialty]” in the orders on this page. This will allow the clerk to schedule them for follow up. You should be putting these orders in a day or two before discharge to ensure timely follow up.
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A “Discharge patient” order will automatically populate on this tab. Make sure to close it if you’re just reviewing the medications and are not ready to discharge your patient yet!
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Click Sign to finalize all your orders and send prescriptions to the patient’s pharmacy.
Instructions
Anything you put in the Discharge instructions will be given directly to the patient. This is where you can remind them what they were treated for, any changes in their medications, any important follow up, and give them return precautions.
Summary
The discharge summary contains a succinct HPI as well as a narrative of what happened to them while inpatient. By keeping running hospital courses on your patients, you can save time on the day of discharge since this will autopopulate into the .IMDCSumm dotphrase. Your senior should be doing this for you during the first part of the year, but as the year goes on and you gain experience, you’ll be able to start doing this as well.
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The hospital course is located in the Discharge Navigator.
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Click the Discharge tab while in the patient’s chart.
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On the left sidebar, select Hospital Course.
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This will open a box where you can free text the patient’s hospital course to date. This should highlight any changes in clinical status, treatment decisions, and new diagnoses – it should not be a daily log of patient subjectives. Pretend that you’re seeing the patient in clinic a week after their discharge… what would you want to read?
If you do a discharge summary on the day of discharge, you do not have to write a daily progress note as long as your exam and subjective are included in the summary.
Order
You made it! Once you have everything confirmed with the patient, SW (for transportation/services if needed), and your senior, you can put in the “discharge patient” order. This will let the nurses print out the discharge paperwork and AVS so they can work on the discharge from their end.