Steps to ADMIT a patient:
- Click the Admission tab (along the left side of the screen).
- Click “Med Rec-Sign&Hold” and then click “Reconcile Home Meds” (option #3). Continue all home meds that you want the patient to receive while in the hospital.
- Click “4. New Orders” to place additional orders.
- Go to order sets: Select “GEN General Adult Admission” and open the order set to fill out each section.
- Click “5. Review and Sign.”
Steps to DISCHARGE a patient:
- Click the Discharge tab (along the left side of screen).
- Click “Medical Reconciliation” then “Next.” Fill out whether you want the patient to go home taking each medication. Remember to discontinue all IVs. Order any additional medications that you want prescribed for the patient when they go home.
- Place Discharge Order (order to have the patient discharged from the hospital) and select where the patient will be discharged to (ex: home or nursing facility).
- Select “Gen Discharge Order” set and fill out. Remember to include any follow ups (PCP, specialist seen in the hospital) as well as any labs that the patient may need at their follow up (CBC, BMP).
Once all discharge orders are complete, you can view the “After Visit Summary” that the patient will receive prior to leaving the hospital.
*** Don’t forget to complete the Discharge Summary for each patient. It is generally easier to complete this note right after placing the discharge orders as the patient’s information will be fresh in your mind at that time.
Change from Observation to full admission inpatient status:
- Order: Admit to inpatient.
- Fill in the order set.
Admitting patient to Hospice:
- Discharge/Readmit: Must discharge the patient from the regular hospital and then readmit the patient into inpatient hospice (Wilcox):
- Patient look up (top of screen). Recent patient. Select.
- Patient station (left, bottom of screen). Select the correct (current) admission. Patient must be discharged from the current admission before readmitted.
- Needs discharge orders, discharge summary, and H&P for new admission for hospice, which can be a summary of the original H&P plus updates from the hospitalization with the plan to readmit the patient for inpatient hospice.
- Palliative medicine/hospice should be consulted (Dr. Baumrucker).
- Open order sets: Comfort Orders.
- Can add Morphine 5mg q4hr inhalation PRN SOB, air hunger.