Discharge Uplift Digital Binder (1)

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Supplemental Resources for Discharge Uplift

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Table of Contents Auto Text Creation and Functionality .................................................................................... 3 Auto Text Copy Utility ..................................................................................................................... 7 DME/Home Health/Oxygen + Acute ...................................................................................... 9 EMATALA Medical Records Request ...................................................................................... 14 Patient Education ............................................................................................................................. 17 Placing Follow Up Instructions from mPage Workflow ............................................ 19 Satisfying Problem List Component Requirements ..................................................... 22 Actions and Situational Awareness for Discharge ....................................................... 23 Work/School Release .................................................................................................................... 24 View Discharge Medication Reconciliation Status ........................................................ 26 Reviewing Discharge Medication List .................................................................................. 27 Discharge Patients to SNF or LTAC ........................................................................................ 28 Problem List- How to Document ............................................................................................. 29 Modifying Dynamic Document .................................................................................................. 30 ED Discharge Uplift Workflow mPage: Nursing ............................................................. 32 Additional Resources ..................................................................................................................... 33

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Tip Sheet:

Auto Text Creation and Functionality

Overview: Auto Text can provide considerable time savings when documenting. Any language generated regularly can be saved and named easily. This document demonstrates how to utilize auto text within Cerner’s PowerChart application. (The scenarios utilized in this document are purely for application purposes and are not intended to teach implied usage.) Auto Text Creation: From the Workflow mPage you can create AutoText from any component that has a text editor toolbar. For example: o Subjective/History of Present Illness o Review of Systems o Objective/Physical Exam o Within the Dynamic Document

From the text editor toolbar: ▪

Select the Manage Auto Text button

▪ Select the blue plus button to create a new phrase

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▪ Enter an Abbreviation and Description withing associated fields

Note: The abbreviation you enter will be the exact abbreviation you will use in components that have a text editor toolbar. It is case sensitive. It is suggested that Personal Auto Text begin with initials.

The second to last icon on the toolbar will allow you to add a template. Templates are premade texts and Tokens are data that is pulled from the patient’s chart.

▪ Click on the Insert Templates/Tokens icon

▪ Click on desired Template/Token ▪ Click Insert

The last icon on the toolbar will allow for a dropdown list of additional phrases you can add to your Auto Text.

▪ Click on the Create Drop List icon

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When the Use Blank Default box is checked an underscore will show as cue that the dropdown can be utilized.

▪ Click on the Add List Item to add phrases or works to the dropdown ▪ Click Create

▪ Enter the text entry in the dialog box ▪ Use underscores to enable tabbing using the F3 keyboard button ▪ Click Save

You have now created an Auto Text. Button options to Edit, Duplicate, and Delete are to the right of the screen.

When utilizing the Auto Text feature make sure you can see the text editor toolbar. ▪ Type initials and a blue box with your chosen Abbreviation will appear

▪ Hit Enter Key OR double click the blue box to pull in Auto Text

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Within the Manage Auto Text window there is a Public Phrases tab. There are presently several phrases created. You can edit these phrases and make them your own by clicking on the Duplicate button.

Follow steps 4-8 to create as your own. The only edit option available is duplicate.

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Tip Sheet:

Auto Text Copy Utility

Overview: Auto Text Copy Utility tool allows you to view and copy Auto Text from a Colleague.

Auto Text Copy Utility: Access the Auto Copy Utility button form the navigation tool bar

Note: You may have to use the down arrow at the end of the tool bar to access the Auto Text Copy Utility

▪ Type the last name, first name of the colleague you wish to copy from ▪ Their Auto Text will display on the left

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▪

Select the auto text you desire

▪

Click Copy button

To copy the complete auto text list: ▪ Click the checkbox Select All button ▪ Click the Copy button

The Copy Auto Text window opens allowing to customize ▪ Customize to save your format ▪ Select the Copy button

▪

Select the Log Out button

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Tip Sheet:

DME/Home Health/Oxygen + Acute

Discharge Needs Quick Orders (QO) mPage: ▪ On menu viewpoint locate Discharge Need QO ▪ Choose DME/Home Health/Outpatient Rehab/Therapies/Post Discharge Tests

Co-Sign is required ▪

Verify “Proposal” is selected

▪

Enter Provider name

▪

Select OK

Note: Any provider can co-sign on the Orders page

▪ Select Orders for Signature (shopping cart)

▪

Choose Modify Details

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▪ Complete order details (All yellow fields are required)

▪

Select Orders for Signature

▪

Select Sign

Print requisitions: ▪

Select the DME order

▪

Right click

▪

Reprint Requisition

Non-specific DME order:

Provider Co-Sign: Any Provider can Co-Sign proposed orders. ▪ From Orders tab, identify DME with? in Other ▪ Right click on order ▪ Choose Accept or Accept with Modify

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Providers: From Quick Orders mPage ▪ Select the Discharge Orders [pp] from ED [PP] + [CS] or Hospital Medicine components

▪

Click Orders for Signature icon

▪ Select Sign or Modify to open the PowerPlan

From New Order component on mPage: ▪ Select Discharge from folder

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▪

Select Discharge Orders [pp]

Note: Recommend saving Discharge Orders [pp] as a favorite)

▪ Select DME/Home Health/Other Services ▪ Check the box to open desired subphase

▪ Right click, modify to enter order details

To place additional orders: ▪

Navigate back to the original PowerPlan ▪ Click the return Icon OR select the bold lettering in the left navigation pane

▪

Select Orders for Signature

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▪

Select Sign

Note: Icons with prescription bottles E.g., Diabetic Supplies will route to pharmacy on file.

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Tip Sheet:

EMATALA Medical Records Request

This document demonstrates how to work with Medical Record Request within Cerner’s PowerChart application. Medical Record Request is used to generate Encounter level reports per patient. You need to be in the patient’s chart for which you are intending to generate a report.

Medical Record Request Open the appropriate patient’s chart ▪ Select Task from the toolbar ▪ Select Print ▪ Select Medical Record Request

The Medical Record Request window appears. All yellow fields are required ▪ Select Event Status dropdown

▪

Select Verified only o

This option would include all published results considered authenticated, verified, or modified (Primary selection)

No need to select Date Range. Clinical Range will suffice for OB or Newborn Transfers

▪ Select the Newborn Transfer or OB Transfer template ▪ Select the Transfer Purpose

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▪

Select ED Transfer Template

▪

Select Transfer Purpose

▪

Select Preview

▪

PDF document will display

▪ At the top of the page select printer icon

Note: This gives the printer that should already be set to the workstation

▪

Select Print

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Tip Sheet:

Patient Education

Workflow mPages Patient Education component is found on the Discharge/Admit, and Discharge mPages. Education leaflets populate based on the diagnosis, this visit and chronic.

▪ Suggested education populates from ICD10 provider diagnosis or “This Visit” problems

▪ Select the appropriate language from the Education Language ▪ Click on the education topic to select/add to patient chart and you will see it populate into the Added Education section of the component. It will print with the hospital Discharge instructions and clinic Visit Summary

Ancillary departments ▪ Click the Patient Education tab on your Framework Toolbar to launch the education window ▪ Double click to add the education to the patient

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Interactive View ▪ Document in iView in appropriate education band (Adult/Pediatric/Diabetes) o Teaching Method and Response o Document diabetes education in Diabetes Flowsheet

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Tip Sheet:

Placing Follow Up Instructions from mPage Workflow

Follow Up Instructions- From Workflow mPage ▪

Navigate to Follow up component

▪ Quick Picks and Saved Templates are face forward

▪ Search follow-up by Provider name, Organization/Clinic or by favorites saved (Saved Templates)

▪

Enter Time Frame Choose Address

▪

▪ Add Comments or choose a predefined comment ▪ Check Save as Template to save this Provider or Location as a favorite ▪ Choose Save

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➢ Follow Up Instructions will be placed into the Patient Discharge Instructions

Freetext- If no Provider/Organization/Clinic is in the database ▪ Click +

Freetext the information into the fields ▪ Add Provider/Location ▪ Enter Time Frame ▪ Add Address ▪ Add Comments

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Follow Up will be added to the Selected Follow Up field ▪ Choose Sign

Note: Once a Provider or Location is placed into the Selected Follow Up field, right click and select “Add to Favorites.” This will now show as a favorite in the Who field when Favorites is selected.

➢ Follow Up Instructions will be placed into the Patient Discharge Instructions.

Removing a Follow Up- From Workflow mPage Follow Up component ▪ Navigate to Added Follow Ups ▪ Select Remove

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Tip Sheet:

Satisfying Problem List Component Requirements

Diagnosis- The Visit

▪

Visit Vocabulary - ICD-10-CM Diagnosis Type - Discharge Classification - Medical Confirmation - Confirmed

▪

Problems - Chronic

▪ Chronic Vocabulary - SNOMED CT ▪ Condition Type - Chronic ▪ Classification - Medical or Interdisciplinary ▪ Status – Active ▪ Confirmation – Confirmed

Must have one of each to get the green checkmark.

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Tip Sheet:

Actions and Situational Awareness for Discharge

Care Team members use Situational Awareness box to give recommendations related to discharge to Physicians and interdepartmental messages. (For example: The Physical Therapist has a recommendation to continue physical therapy after discharge).

Situational Awareness ▪ Check Include all ▪ Choose Save

Note: •

Actions box is only for providers to track tasks • Situational Awareness does not print to the discharge paperwork • Directions must be in Patient Education to print on discharge instructions • Writes to the Multi-Disciplinary Rounding(MDR) worklist Comments column, but MDR does not write back

If item has been addressed/completed, delete it. Users can only edit their own but delete anybody’s entry.

Patient Education = Instructions/Directions Follow up = Future appointment(s) DME = Located in Discharge Orders PP

Etiquette •

Keep it short

• If your name does not populate from title, include your name and service in comment • Start comment with “for Discharge”

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Tip Sheet:

Work/School Release

Overview: The Work/School Release is provider’s instruction for when a patient can return to work/school.

Creating Work/ School Release: ▪ Navigate to All Provider Workflow mPage or Discharge mPage Note: BTMC May 2023 pilot mPage title reads Discharge/Admit- BTMC ED Only

▪ Complete all fields within the Work/School Release Form ▪ Select Sign and Submit

▪

Select Sign and Print

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Locating the Completed Work/ School Release:

Option 1 ▪ Locate Documentation on Table of Contents Menu, then select Discharge Work School Release

Option 2 ▪ Locate Clinical Notes on Table of Contents Menu, then select Patient Forms Folder ▪ Open folder titled Work/School/Agency Application Folder ▪ Click Discharge Work School Release

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View Discharge Medication Reconciliation Status

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Reviewing Discharge Medication List

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Discharge Patients to SNF or LTAC

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Problem List- How to Document

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Tip Sheet:

Modifying Dynamic Document

Creating Dynamic Documentation- From workflow or Discharge mPage ▪ Navigate to Create Note section on workflow ▪ Click blue hyperlink on desired Note

Note: Only click blue hyperlink once. Every time the blue hyperlink is clicked it creates a new document. You should only have one document open. See steps below to view In Progress note.

▪ Complete the Note/Discharge Instructions. If not completed, save the document, and resume/complete the documentation at a later time.

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➢ Save = Information saved on Dynamic Note, note will still appear in chart.

➢ Save & Close = Saves Dynamic Note, closes document in chart. Removes the note from Documentation view and will take you back to the mPage view. ▪ Refresh Documents component

▪ Click on caret to open In Progress view (if collapsed)

▪ Left click on blue hyperlink (once) to modify, complete your note

➢ Sign/Submit = Completes Note, only able to add an addendum. If additional information was added after Sign/Submit a new Discharge Note will need to be created.

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Workflow:

ED Discharge Uplift Workflow mPage: Nursing

ED Discharge Uplift Workflow mpage: Nursing Discharge Discharge ▪ IV stop time - Required for billing ▪

Problem List - O ne medical problem “This Visit” (ICD -10) must be entered by provider and one chronic problem or no chronic problem must be entered by nursing or provider ▪ Patient Education - Required ▪ Follow-up - Required ▪ Order profile - Required - need ED discharge to order ▪ Enter medication next dose electronically on patient discharge instructions ▪ Print discharge instructions (if not done by ED Provider) ▪ Scan signed signature page of patient discharge instructions into chart ▪ Document ED Disposition Documentation form from mPage ▪ Checkout Problem List - Enter o ne medical problem “This visit” (ICD -10) must be entered by provider and one chronic problem or no chronic problem- entered by nursing or provider ▪ Patient Education - OK to OVERIDE ▪ Follow-up - OK to OVERIDE ▪ Order profile - ED Transfer to other facility order ▪ Print EMTALA form (#1413) ▪ Fill in form ▪ Have patient and physician (if needed) sign form ▪ Make copy - send copy with patient ▪ Scan original EMTALA form into chart ▪ Print packet - Medical Record Request - ED Transfer Template ▪ Print patient discharge instructions (if needed) ▪ Have patient sign discharge instructions ▪ Scan signed signature page of discharge instructions into chart ▪ Document ED Disposition Documentation form from mPage ▪ Checkout IV stop time - required for billing ▪

EMTALA Transfer ▪

Admit ▪

IV stop time - required for billing ▪

Problem List - Enter o ne medical problem “This visit” (ICD -10) must be entered by provider and one chronic problem or no chronic problem- entered by nursing or provider ▪ Patient Education- OK to OVERIDE ▪ Follow-up- OK to OVERIDE ▪ Document ED Disposition Documentation form from mPage ▪ Checkout

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Additional Resources

Ancillary (Demo)

Beh Health Providers (Demo)

Beh Health Nursing (Demo)

Care Coordination (Demo)

Periop providers (Demo)

Providers (Demo)

Obstetric nursing (Demo)

Nursing (Demo)

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