Soarian Discharge Instructions

1. Soarian Discharge Instructions RN/Provider

2. introduction • Soarian Discharge Instructions are electronically generated patient discharge instructions that are completed by the: • RN/C3 • Provider • Why implement electronic discharge instructions? • Provides the physician/mid-level provider and the nurse with a method of communicating to their patients exactly how to care for themselves following discharge. • Provides the patient with a more individualized, comprehensive, legible set of discharge instructions.

3. Objectives • Understand policy/process • Navigate through the discharge instruction module • Understand the provider role in module completion • Understand the nursing/C3 role in module completion • Understand how to print the report for the patient/chart • Understand downtime procedures

4. Policy/process • All patients are to be provided with discharge and medication instructions . • The medical provider and the nurse/C3 will both complete components of the electronic Soarian discharge instructions. • Either discipline may initiate the module at any point during the patient’s stay and save “in progress”. Providers will save the module as “in progress”. The nurse will perform a final review of the discharge instructions and save the module as “complete”. • If the provider elects to not complete their module component, the nurse will revert to the paper process using the Discharge Instructions and Addendum forms NSG-001 and NSG-002 . • If the module is started by nursing/C3 and provider elects to not compete, the nurse will mark the discharge instruction module as erroneous in the system and revert to paper. • Another option is for the nurse to offer at the elbow assistance to the provider in completing their component of the discharge instructions while the provider is signed in.

5. Discharge Module Overview- accessing • Access the module via: • The Charting tab • Assessments • Filtered List • Discharge Instructions

6. Discharge Module Overview The Module is comprised of six chapters. The first two chapters are for provider completion: Discharge Instructions “Core/Quality Measures” The last four chapters are to be completed by nursing and/or C3s: Special Care Community Resources Vaccine Record Instructions

7. Starting the Module Either the provider or the nurse/C3 may begin the discharge instructions and save the module as “in progress”. NOTE: Providers will always status as “in progress”. Nurses will perform the final review and status as “complete”

8. Completing a module in progress Once the module is saved in progress, accessing the module for completion is done via the charting tab under “scheduled/incomplete assessments: Click on the Discharge Instructions assessment to complete.

9. Nursing: Once all six chapters have been completed, change the status from “in progress” to “complete” and save.

10. Provider Role Provider Providers are responsible for completing the first two chapters and the third chapter (special care) if applicable. REMEMBER: These instructions will be read by the patient –keep them simple and patient friendly. Do not use medical terms, abbreviations, etc.

11. All BOLD fields are required to be filled in – • Principle diagnosis • Diet • Discharge Activity • Follow up with/when • Discharge Standards are a generic guideline for completing the patient restrictions. This will pre-populate the various restrictions fields and can be revised/individualized to meet patient specific needs. • If the patient condition is not listed in the Discharge standards, all restrictions can be manually selected. Provider

12. Provider • Core Measures is a provider chapter. • All required (bold) fields need to be completed for core measures. • For patients discharged from the Detox unit, select “Behavioral Health Patient”. This will clear most required (bold) fields.

13. VTE Core Measures • If the provider elects to not place the patient on VTE prophylaxis and answers the VTE questions via the VTE order-set on admission – the reasons will pull forward to the discharge instructionmodule. Provider

14. Provider Once the module is saved as “in progress”, ALWAYS return to the assessment browser. Failure to return to the assessment browser will lock the module, preventing completion by another clinician.

15. NURSING ROLE Nursing • Special Care chapter is completed by nursing or providers. • Wound care • IVs, Drains, Tube, Ostomy care • Equipment

16. Nursing The community Referrals must becompleted by C3s or nursing staff at any point during the patient’s stay if applicable to the patient.

17. Nursing Vaccines: nursing will complete whether the patient received the pneumonia and/or flu vaccine during this visit.

18. Nursing • The Instructions chapter topics addressed are: • Stroke • CHF • Crisis Intervention • Smoking • Handouts/materials given

19. Printing Nursing • BOTH the: • Discharge Medication Reconciliation and the • Discharge Instructions Module must be saved as complete before the instructions can be printed from Soarian. Do not print until the patient is ready to receive the instructions. This will allow for final edits to the instructions by all clinicians. Two copies will automatically print – one for the patient, one for the chart. When the Warfarin education assessment is completed electronically at any time during the patient’s stay, this information will automatically pull onto the printed discharge instructions.

20. Printing Nursing Navigate to the patient record Confirm Discharge Medication Reconciliation has been completed Select Print

21. Select the Discharge Instructions When discharge instructions are completed electronically, the discharge medication list will be included in the printed documents Print (2 copies will print) If the provider elects to not complete the discharge instructions electronically, you must then print the Discharge Medication List.

22. Printed Instructions • Fill in “last dose given” and “next dose due” for all medications. • Review all instructions with patient/family • Have patient sign both copies • The nurse signs both copies • Place a copy in the paper chart.

23. Downtime • During system downtime, revert to the paper process using forms NSG-001 and NSG-002 • The paper discharge instructions do NOT need to be back-charted into Soarian upon system return.