1 Online Discharge Summary Tutorial Create Online Discharge Summaries & Addendums Table of Contents...
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Transcript of 1 Online Discharge Summary Tutorial Create Online Discharge Summaries & Addendums Table of Contents...
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Online Discharge Summary Tutorial
Create Online Discharge Summaries & Addendums
Table of Contents Start
• From POE • From the Portal • After Signing the Discharge Order
Enter & Edit
• Access Clinical Data• Enter Data
• In Progress Documents• Completed Documents
Complete
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Start a Summary or Addendum
There Are Three Ways To Start:
1) From the POE Main Menu2) From the Portal
For Discharge Summaries Only: 3) Directly After Signing the Discharge Order
From the POE Main Menu
1) Select patient from the POE Dashboard (inpatients only) or via the Other Patient link at the top of the dashboard
2) Click the Discharge Summary link on the POE Main Menu
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From the Portal
1) Click the CareWeb Link on the Left Side of the Portal
2) Select Discharge Summary
3) Enter CCC Key
4) Search For Patient By Floor, Name or MRN
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After the Patient is Selectedthe Discharge Summary Information is Presented
Click the Appropriate Link To:
• Find the Patients For Whom You Have Started A Summary
• Start A New Summary or Addendum
• View & Print Documents
• Edit In Progress Documents
• Find a New Patient (if Accessing via the Portal) Or Exit
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Directly After Signing the Discharge Order
When you sign the discharge order in POE you must firstselect who is responsible for writing the Discharge Summary
If the default name is not correct, type the full or last name of the
responsible person into the textbox and click
‘Lookup’
You will be presented with the related names. Click the name of
the person you want and then press OK
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Select this option and you will be presented with the sections of the Discharge Worksheet that will be automatically
imported into the summary
Click Save/Menu
After selecting the responsible summary writer and reviewing the worksheet and medications, you have the option of
proceeding directly into the discharge summary after signing the order
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This is the main screen from which you can start, edit & complete a summary. There are three main sections:
• Links to Edit Each Section of the Summary• Patient Profile Information• Ongoing Text of the Summary
Discharge Summary Main Screen
Enter & Edit
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The Online Discharge Summary presents you with data from the following sources to
help you build your summary:
• Team Census Notes
• Discharge Worksheet
• OMR Problem Lists
• Notes – Past Discharge Summaries, Operative Notes, & all other OMR Notes
• All Online Reports – Including Cardiology, Radiology, & Pathology
• Results – Blood, Urine, CSF, Microbiology, etc.
Access Data
Click the appropriate button to review data and to copy and paste it directly
into the body of the summary
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To Create the Summary, Enter Data and Text into the Corresponding Text Boxes
Also Note: Discharge Worksheet Data Is Available For Appropriate Sections Click the Blue Link To Default the Information Into the Summary
When Finished With Each Section, Click: Save/Continue to Proceed to the Next Section OR Save/Menu to Return to the Home Page
Enter & Edit
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Print A Summary or Addendum
In Progress Documents
At any time a draft of the summary or addendum can be printed. Click the Print Draft button on the main screen
Select the sections you want and click Print. If you would like to print all sections, just click Print.
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Print A Summary or Addendum
Finished Documents
Select the ‘View/Print’ link from the Discharge Summary Information page. To print the summary, click Print
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Complete A Summary
• Complete: Sends Summary to Attending For Signature
• STAT Complete: Sends to Attending & Prints Locally
• Exit: Closes Application, Writer Can Return Later
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Selecting Either Complete Option Takes You To This Screen:
Select the Attending MD responsible for signing the summary (only available if more than one Attending was assigned to the patient during the current stay)
Press OK
If STAT Complete Was Selected, Pressing OK Will Immediately Print the Summary At Your Local Printer