Discharge Summary/Note

[pmalloy (Patrick Malloy)]

As a behavioral health provider, it is good practice to have a discharge summary when somebody is done with therapy. We don’t always know that a person will be done with therapy on a person’s last visit, so it doesn’t seem like the solution would be to attach something to the patient’s last encounter note. We would want this to be available to export out of somebody’s medical records so that there would be reason given to why somebody ends therapy.

I read the following and it looked like transactions might work for this, although they might not have been specifically designed for this:

Patient Discharge

bradymiller wrote on Thursday, October 29, 2015: Hi, Transaction sounds like a good route for the form since won’t be based on encounter and can configure whatever you want for your discharge form. The nice thing there is that it could be done in a way to record more than 1 discharges from the clinic. For example, discharged after issue #1 is resolved(or is a sociopath). Then returns again for issue #2 (or is less of a sociopath). Bringing that into the patient searching sql query will likely…

Transactions

fr4nkie wrote on Thursday, May 22, 2014: The only transaction with an internal/external variable is the referral. As far as the other transaction types, the only option is text input. Also looks like the referral/counter referral is the only transaction that can be printed by itself. All other transactions must be printed via the patient report module, where all entries are printed on the same page. This is what makes the non-referral transactions and notes redundant, in my opinion. I understa…

Does anybody have any suggestions for how to accomplish a simple, non-billable discharge note that would be available to export in a patient’s record? Thanks!

[sjpadgett (Jerry P)]

I believe a Clinical note would suffice using Discharge Summary Type.
This note is exported in CCDA in the narrative.

Also if it needs to be more structured perhaps a questionnaire using a LOINC panel from encounters.

[dmnlbh (Dava Muserallo)]

Where would you access this Clinical Note form? Is this something we would need to create?

Also, I am familiar with LBFs but not the CCDA. Not sure how this plays into forms.

[dmnlbh (Dava Muserallo)]

Harley Tuck is helping us with this. We enacted these steps, and now I’m unsure of how to proceed to access the Discharge Summary Note.

• To address Dava’s question in the forum, the Clinical Notes form in your system is disabled. You’ll need to go into Admin/ Forms/ Forms Administration and finish installing it; see 1st picture below. Once enabled it should be in the list of Clinical Forms that are available in the encounter menu.

• The next item discussed is the c-cda module, which is enabled in your system, and accessed through the main menu: ‘Modules/ Carecoordination’ (2nd pic below).
  Once the C-CDA module is opened from the main menu, you can select a patient record (check box on right side of screen (rectangle) then click either the ‘View C-CDA’ (arrow) or the big blue ‘Send To’ button at top left, and select HIE, EMR Client or Download. However, a global setting has not been set so trying to download or view the C-CDA evokes an error message, ‘Message: Please Enable C-CDA Alternate Service in Global Settings’. It is located in Admin/ Globals/ Connectors tab (last pic below), At this point I have not done that, but if it is turned on you can explore the content it offers.

Everything has been activated as Harley outlined, just need next steps!

Dava

[sjpadgett (Jerry P)]

First the Clinical Notes form for v7.0.0 is turned on by default. The install Clinical Notes from forms admin is a different form and old.
Second if you want a Discharge Note to appear in CCDA then you need to use the form I show above in screenshot.

[dmnlbh (Dava Muserallo)]

So, the clinical notes does appear for me within an encounter. That is great! I was able to find the Discharge summary note and attach it to an encounter. I guess the clinical note can’t be a stand alone outside of an encounter, is that correct?

I did want to limit the note type options. I found the list and have it limited to only a few but they all still appear. Any thoughts on why that might be happening?

Dava

[dmnlbh (Dava Muserallo)]

I also can’t seem to figure out how to identify the clinical note as a discharge note without opening up the encounter form. When I go to reports and the clinical note appears in the list under the encounter (see below), but again, it is not easily identifiable as a discharge note.

The point of “discharging a client” for us is to note we are no longer clinically responsible for treating this individual for their mental health concerns. I see this as a liability issue.

Without having to individually dig out the information, is there a way to identify those clients where a Discharge note has been created? The clinical note doesn’t show up in reports when generating them.

I’m struggling a bit with the need to be able to easily access information but into a database. I guess a coupe of queries a day keeps the doctor away, but this is driving me a bit nutty.

Best,
Dava

[htuck (htuck@mi-squared.com)]

Hi @dmnlbh
I do not know why the ‘Clinical Notes’ list will not remove inactive items from the working dropdown. It has the feel to me of a situation where a code update in a previous version broke something that has not yet been corrected. As I write this the OEMR public demo is down so I can’t double check it there. Luckily the working list isn’t too long so shouldn’t get in the way too badly.

As far as the Discharge Summary goes, we have a situation where things are not always named what we expect.
I made a Discharge Note in an encounter. And remember you can always create one last encounter just to contain the discharge summary.

The Note appears in the encounter summary.

Then, to print out the report that would contain the Discharge Summary, you open the Patient Reports from the Dashboard menu

Check whatever information you want to include in the report, but be sure you select the encounter with the discharge summary in it (round rectangle below)
Click ‘Generate Report’ button in ‘Patient Report’ (arrow)
dc03

and see the D/C summary in the report. The whole text of the discharge summary will appear in the report.
dc05

As far as finding the Discharge Summaries that have been written, Report / Visits/ Encounters has a search filter for ‘Forms Esigned’ which should return a list of all the forms that have been e-signed.

This presumes that the therapist writing the Discharge Summary would e-sign the form, and/ or the encounter it’s in but that seems like a pretty reasonable expectation.
Best- Harley

[dmnlbh (Dava Muserallo)]

Hey Harley! Thanks for the follow up! I was able to get the discharge summary note to show up in the generated report, so thank you for that. Part of my concern was in the report list, it just says clinical note, so if multiple clinical notes are used, then how would you tell the difference. From the dropdown, it looks like the discharge summary may be the only one we use.

I did to the report function you mentioned and the test sample did not show up for me. I tried a larger date range and there were hundreds of forms esigned. Is Forms E-signed supposed to only pull up the clinical notes form? What other forms might it be pulling if we are only using encounters at this point?