Discharge Summary - Provincially Standardized Templates

Standardized charting, including Problem Oriented Charting (POC), is most efficient when started at the beginning of an inpatient encounter. Structured data (e.g., problems, medical history, medications) should be maintained, then incorporated into notes or summaries. Revising structured data throughout an encounter eases discharge documentation, especially when using standardized templates that pull in the latest structured data. 

This section explains how to get the most out of the standardized Discharge Summary templates in  Connect Care. 

Interactive Documentation

Connect Care summative documentation templates integrate structured data management with easily readable prose, allowing the author to update information seamlessly while composing summative documentation. This is accomplished through "interactive documentation":

A key to good interactive documentation is regular use the "Refresh" button appearing (configurable) in note editor button bars. This ensures that note content reflects the latest edits or updates to structured data.

AHS Discharge Summary Templates

Three variants of a provincially standardized discharge summary template are provided for easy selection in Connect Care documentation workflows.  All share the same (required) header and identification information. They also have the same overall structure, reflecting multi-stakeholder consensus among those who consume discharge summaries distributed to Netcare and community Electronic Medical Records.

Headings 

A "headings" template sets up a discharge summary with expected and required sections and subtitles. Users can use their own SmartTools (SmartPhrases, SmartLinks, SmartText, SmartLists) or dictation to enter content into each section. Wildcards (***) are provided to ease moving from section to section (F2 key).

Basic 

A "basic" template sets up a discharge summary with expected headers, all required sections and common content pulled from sections of the chart. Users can use SmartTools or dictation to enter additional details. SmartLists and wildcards (***) are provided to facilitate entry of some content.

Advanced

An "advanced" template sets up a discharge summary with expected headers, all required sections and common content from other sections of the chart, as well as text composed from data captured as part of problem oriented charting workflows. SmartLists and wildcards (***) are provided to facilitate entry of some content.

Discharge Summary Workflow

Ideally, a discharge summary will be prepared after all other tasks in the Connect Care Discharge Navigator have been completed. These include updating the problem list, completing medication reconciliation and documenting follow-up arrangements. Given this information, the basic and advanced templates are pre-populated with much of what is needed and workflow burdens are greatly reduced.

Specialty Customizations

Discharge summaries may need to reflect unique circumstances of specialty contexts (e.g., obstetrics and delivery). If an AHS standard discharge summary template (as above) is used, it will automatically detect a different clinical context (e.g., emergency department) and switch to the appropriate variant.

If a needed specialty variant is not yet available in an AHS standard template format, it is suggested that users select the "Blank" or "Headings" option and add specialty-specific content as appropriate. Use help.connect-care.ca to submit a request to have a standardized specialty template developed and added for automated substitutions.

Standard Discharge Summary Sections

AHS summative documentation norms expect a discharge summary to include standardized headings and subheadings. The "Headings", "Basic" and "Advanced" variants of Connect Care's standard templates all have the same headers and headings, as below. The "Basic" and "Advanced" templates have more Smart content and interactive features (remember to use the "refresh" button to updated SmartTool content before saving or signing).

Header

The top (header) section of a discharge summary records encounter bounds (e.g., admission and discharge dates), accountable providers, information about the facility and the goals of care designation active at the time of discharge. Some text (usually labels) is in a dark blue font. Selecting this will open a popup editor or, alternately, go to parts of the chart where the relevant data is stored and updated. Use these interactive charting features to edit structured data "in-place". Remember to refresh.

Overview

This section can be used to provide a succinct overview of the patient's reason and mode of presentation initiating the encounter. The basic and advanced templates have interactive features allowing structured data to be used to compose a consistent patient overview.

Most Responsible Diagnosis

This mandated information should reflect the admitting diagnosis, presenting complaint or principle hospital problem. The basic and advanced templates pull the data in automatically. Interactive (dark blue) text can be selected to update the principle problem.

Preliminary Cause of Death

A preliminary cause of death must be included in a deceased note. It is entered in the deceased navigator (found within the discharge navigator) when the time and date of death is recorded. Advanced templates allow the section header (dark blue text) to be selected for rapid access to revisions of the date/time of death and the preliminary cause of death.

Hospital Problems

Health problems addressed during the inpatient or emergency department encounter are listed in this section. Basic and Advanced templates pull this information in automatically, with interactive links to the problem list activity where updates can be made.

Hospital Course

The hospital course section should be used to provide a high-level, concise, ideally point-form summary of key developments during the inpatient or emergency department encounter. Basic and Advanced templates pull this information in from data already in the health record. Interactive headings (dark blue text) allow for edits to the source content before refreshing and updating in the template.

Discharge Plan

The discharge plan is highlighted in all standardized templates. It should indicated, for each active hospital problem, what assessments and plans pertain to post-discharge care. The Advanced template automatically pulls this information from the most recent assessment and plan notes on the chart.

Follow Up Arrangements

Community clinicians (discharge summary consumers) cite this as the most important content in a discharge summary. It should clarify who will follow up health issues post-discharge, including accountabilities for things like laboratory test and medication management. The Advanced template allows the author to select (SmartList) the level of detail to be included. Things like arranged outpatient appointments are automatically included. Information about community supports can also be selected for inclusion.

Medications

A complete list of medications that the patient should be taking at discharge is required. The Advanced template allows authors to select (SmartList) 3 levels of detail, with the simplest indicating "No change" and the most complex providing a full medication reconciliation accounting of continued, changed, added and discontinued medications.

Interventions

An optional (SmartList controlled) interventions text block facilitates summarization of the major (operative or procedural) interventions performed during the encounter.

Other History

An optional (SmartList controlled) text block allows additional information, such as medical or social histories, to be pulled from structured chart data. Authors can indicate that such information is already documented in a current history and physical examination note.

Finding Standardized Templates

The discharge summary templates (Headings, Basic, Advanced) can be found and used by four easy means:

Blank Note with SmartLink

A blank note can be initiated within the inpatient chart "Notes" activity. Be sure to select the correct Note Type (Discharge Summary) and charting service (inpatient provider service most responsible at the time of discharge) at the top of the note editor. The following dot phrases can be used to pull in one of the three standardized templates.

Notes Activity with New Note

All inpatient charts have a “Notes” activity. Select this, then the “Discharge” tab within. A “Create in NoteWriter” button appears at the top of the Notes activity. Selecting this opens a popup that presents options for loading any of the standardized discharge summary templates.

Discharge Navigator Speed Button

The Discharge Navigator (present in all inpatient charts when a prescriber is logged on) has a "Discharge Summary" section near the bottom of the navigator. This reminds that other navigator tasks should be completed before a discharge summary is composed.

Speed buttons are provided for Headings, Basic and Advanced templates. Clicking on the desired button will open a note editor with the correct document type and template automatically loaded.

Chart Sidebar Link

The inpatient chart sidebar is present by default as a collapsible right-most section of all opened inpatient charts. It has a "Notes" item (bottom left column of index). Selecting this presents a secondary sidebar menu that includes a link for "Discharge Summary". Selecting this, in turn, presents a list of standardized discharge summary templates. All are links. Selecting the appropriate one will open a note editor with the correct note type and template pre-loaded.

Pending, Sharing and Signing Summative Documents

Connect Care automatically shares key summative documents with the Alberta Netcare Portal electronic health record and with eDelivery-compatible electronic medical records (EMRs). Automated sharing is triggered when an eligible note is signed (co-signed in the case of trainee-authored notes). If the same note is later edited and re-signed, a new copy is distributed to external systems. 

Summative document contributors should “pend” or “share” their work, saving "signing" for the most responsible prescriber after all reviews are complete. A document should be signed just once; and so shared just once.

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