Embedded Files
Once you have decided that a patient can be discharged from the CDU, please follow these steps to properly discharge the patient.
1) Discuss discharge with the patient and nursing staff (+/- Care management).
Start the DC process by informing the patient of their discharge, as well as any medications or follow up plans you feel are required.
Then let the nursing staff know of your plan to discharge. This will give the patient and nursing an opportunity to communicate any concerns or barriers before you've done a bunch of work to discharge the patient. If the patient has home health needs, is going to a facility or otherwise care management has been involved, now is the time to inform them of the discharge too.
2) Complete a Discharge Medication Reconciliation
Don't worry, this is pretty easy. This is when you will be prescribing any medications to be taken after discharge.
Please see the separate tutorial on how to complete a DC med rec
3) Complete a CDU Discharge Note
Please use the SmartPhrase ".iescdudischargenote". to document the patients stay in CDU as well as discharge plans.
CDU Course
This section should be used to document the interventions and progress during the patients' stay in CDU
Physical Exam
This section record your discharge exam after visiting with the patient. This section is required for billing purposes.
Discharge Medications
This section documents the patients medications at time of discharge, including any chronic medications, any changes to their home medications and any new prescriptions at time of discharge.
For this section to be completed, a DC med rec has to have been completed. Please see how to do that here.
Problem Based Assesment and Plan
Please use this section to document each problem that was dealt with in CDU and what the discharge plan is for the patient
Example
Problem 1 description and plan: Cellulitis - improved on Unasyn
a. Plan: Discharge on oral Augmentin for 7 day course, followup with PCP for wound check within one week
Discharge Condition, Orders and Followup
This section documents the condition of patient at discharge (necessary for billing) and more importantly where they will be discharged to and any orders that will need to be executed for the patient after discharge.
This is where orders for a discharge to a facility or discharge with home health are placed.
In the "Time Spent" category, this will almost always be "More than 30 mins"
4) Fill out Discharge Instructions and Submit a Disposition in Epic
Take a moment to write out any instructions that you want to appear directly on the patients' discharge papers, including appointment times and locations, specific medication instructions etc.
Once all of this is done, finally you can click the "Discharged" button on the Disposition section of the Dispo tab. This will turn the patient green on the track board and alert the nursing staff that it's time to get the patient rolling.
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