Nursing Discharge Workflow Guide
Discharge Workflow Page
1. Once in the patient chart, select Nurse View in the menu bar, and navigate to the Discharge tab.
2. Scroll through the different sections of the workflow page to fill out the required sections, indicated by a red asterisk. These will turn to green checkmarks as they are completed.
3. Any documented chronic problems will display in the problems list section. You will also see physician diagnoses, as indicated by This Visit under the Actions column. To resolve problems that are no longer active, click Resolve.
4. Click the arrow under the Discharge PowerForms section to document on the Nursing Discharge Summary and Valuables/Belongings forms to complete this documentation as appropriate.
5. Your providers will be completing their discharge medication reconciliation in their version of the discharge workflow process. You can see the status of the meds rec as well as the medications the patient will be taking following discharge in the Discharge Medications section. The pill bottle icon indicates a prescribed medication, and the scroll icon is a documented home medication.
6. Complete IV Stop Times documentation within this section if not already complete. This section will have a green checkmark if this information has already been documented, or if it is not applicable to the patient.
7. Patient Education can be added in the Patient Education section. First, suggested education will display based on documented physician diagnoses and chronic problems. You can also search to add additional education. Add education by clicking on the education piece once. Double-clicking will add it twice, but it can be removed by clicking the “X” in the added education section.
8. Medication Leaflets can also be added in the Patient Education section. First, suggested medication leaflets will display based on the physician’s completed discharge medication reconciliation. You can also search to add additional medication leaflets. Add leaflets by clicking on the specific medication once. Double-clicking will add it twice, but it can be removed by clicking the “X” in the added medication leaflets section.
9. Follow-Ups can be added by your providers in their workflow pages, but additions can be made by selecting a Quick Pick or searching for a Provider/Location, and modifications can be made by clicking on existing follow-up instructions and clicking Modify or Delete if it is no longer needed. Scheduled appointments (if any) will flow into the section at the bottom.
10. Free-texted Patient Instructions can be added in this section. Your providers will be able to add this information in their discharge workflow process as well.
11. If any To-Do’s & Notes were added in the Nursing Handoff workflow page, you would also be able to see them on the discharge workflow page.
12. Post-discharge Goals and Interventions can be added by clicking on the plus sign within this section.
13. As soon as you and the provider have completed all needed discharge documentation, click to create Hospital Discharge Instructions
Hospital Discharge Instructions
1. After you have gone through the different components in the discharge workflow page and clicked on Hospital Discharge Instructions to create your note, you will be brought to the Documentation section of the chart. From here, you can see how the information entered by you and the provider are flowing into the discharge instructions to give to the patient.
2. For Medication instructions, all this information is pulling from documented home medications from the patient’s admission, and now the provider’s discharge medication reconciliation. It clearly outlines new, unchanged, or medications to stop taking. All columns below (except for “What” and “How Much”) can be edited with free text added.
3. You can remove each section that is not applicable to the patient you are creating discharge instructions for by clicking the “X” next to each line item or broader section
4. If you have already clicked to create the instruction note, but the provider updated the meds rec, or you need to add something else back on the workflow page to then flow into your instructions note, you can refresh the different components of the note to pull in the most updated information without having to start from scratch.
5. You can also insert free text anywhere you see the arrow highlighted below to get a text space to free text and/or and leverage the auto text feature (by typing a period to pull in Cerner-created and your personal auto text phrases) if there is anything additional that would need to be added.
6. Once you have made any changes or additions needed, click Sign/Submit if you are completed with the discharge instructions. You can also click Save if you are needing to come back to finish editing later.
7.You will then get this pop-up where you have the option to forward to a provider if needed, otherwise you can click “Sign & Print” to sign off on and print the instructions.
8. If you click the Sign & Print option, you will be brought to the Medical Record Request screen, which is where you will be able to print the patient instructions for discharge. If it doesn’t default automatically, choose Document Template as the Template, and select CLIN DOC – Discharge Documentation under the sections. Then select your printer (device) and click “Send” to print. You can also preview the document prior to printing.
9. If you needed to print the instructions later, you can go into the note in Documentation, right click on the note in the view pane, and select Print.
Printing a Transfer Packet
1. To print a transfer packet for the inpatient summary, navigate to Medical Record Request in the toolbar. This will bring you to the same screen you’ll see when printing a document.
2. Select your template, your purpose, choose the sections you want to include (all if applicable), select your printer (device), preview if you’d like, and then click Send.
