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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

Print

• 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