Discharging a patient is one of the most important parts of a patient's hospital stay because it can set up their success outside of the hospital and prevent them from returning or having other complications. The process of discharging patients from the VA is as follows.
medication reconciliation aka discharge instructions, part b
Step 1: The first part of an accurate medication reconciliation is to see what medications the patient is prescribed as an outpatient. Outpatient medications can be viewed by going to the "Meds" tab of the patient's chart and looking at the bottom-most section labeled "Outpatient Meds." Here medications are listed as "Active," "Active/Susp" (indicating they have been sent but not yet filled by the patient), "Expired" (meaning the refills on this medication have run out - either purposefully or not purposefully), and "Discontinued." This should have been looked through and confirmed during the admission process.
The section above "Outpatient Meds," labeled "Non-VA Meds" are medications filled by non-VA providers that have been entered into the system by the patient's VA provider. These may or may not be accurate and need to be reviewed with the patient.
Often, medications prescribed in the ED will populate in the "Outpatient Meds" section. These are one time orders and will be at the top of the list. Make sure to discontinue these.
*Also, please note your team pharmacist can work with you to make sure the patient has all the refills and appropriate meds with discharge: let them know about 24 hours before discharge so they can start working on it.
Step 2: Prescribe any new medications you may want to discharge the patient with. This can be done by going to the "Orders" tab and clicking “Add new order” >> “Outpatient Medications” >> type the medication name, # of pills needed, if refills are needed.
Click on “Window” to have the medication sent to Outpatient pharmacy. If you need the medication to be filled ASAP, call the outpatient pharmacy at x58235.
Let the nurse know so they can call pharmacy to make sure the medications are handed to the patient prior to discharge.
Note: if you are prescribing narcotics, you must complete a paper prescription. Controlled substance prescriptions can be obtained from the chief resident’s office. You must use your VA DEA number, which can be obtained by calling the outpatient pharmacy.
Step 3: Create the note - Discharge Instructions, Part B. This will pull all the medications in the "Outpatient Meds" list that are "Active," "Active/Susp," and "Pending," including all of the new medications you ordered. It will pull the medications in alphabetical order and includes medical supplies. We ask you to rearrange the list in a way that would be common sense for the patient as this is the list they go home with. i.e. For your COPD: Albuterol, Symbicort. For your coronary artery disease: Aspirin, Atorvastatin.
There is also a section for a description of what happened to the patient during their hospitalization. Please write a few sentences in non-medical jargon for the patient.
Discharge instructions, part a
This is another required note for discharge. This takes you through a series of prompts, making sure those leaving with diagnoses of heart failure and STEMI leave with appropriate guideline directed medical therapy if possible. It also prompts about appropriate vaccination status. You can view your patient's vaccination history on the "Cover Sheet" tab in the bottom left hand corner labeled "Recent Immunizations."
When Part A & Part B are completed and your patient is ready to leave, place the discharge order in the "Orders" tab. You can place any details in the comment section - like the ETA of the patient's ride or if you are waiting for the outpatient medications to be filled.
This needs to be completed within 24 hours of discharge or at the time of discharge if the patient is going to SAR. Discharge summaries are the way the outpatient PCP knows what pertinent things happened during an inpatient hospitalization and if there are any particular things they should follow up on. Follow the prompts through the discharge summary with what should be added. Under "Hospital Course" is where you should have a narrative summary of each major problem the patient had during the hospitalization, not merely copying and pasting the assessment and plan from the last progress note.
Work excuse note/Letterhead
Beneficiary Travel Note
Some patients may need a Beneficiary Travel Note in order to get transport on discharge from the VA. These patients are generally those needing transfer to other hospitals in an ambulance (Ie. SAR, BLS/ACLS level transport etc). You will be made aware of who will need this note by your Case Manager/Social Worker but it is good to anticipate if your patient might need one filled out. See the Transfer Policy for further information on how to transfer. To create a BT note:
Click "Note" tab >>"New Note">> type "Beneficiary" >>select "Beneficiary Travel (BT)"
Special Mode Transport: Yes, (insert reason for needing BT note ie. severe deconditioning)
Inter-facility Transport: Yes, (insert level of care of transport ie. BLS, ACLS)
Day to Commence: Today >> length of time: 1 year
Fill in: To and From Addresses (one should be the DC VA address)
All Authorized >> Round Trip
If your patient dies during the hospitalization
Notify your attending when a patient dies and inform the next of kin or POA. In CPRS, you must write a Death Summary note as well as a Discharge Summary, but do not need to complete Part A or Part B. You or the patient's nurse should let the AOD know, who will coordinate with Decedant Affairs on the appropriate paperwork needed and coordinate with the family for funeral arrangements.
Transferring to another hospital
If you are transferring a patient to another hospital, they still need a Part A, Part B, and Discharge Summary. See the Transfer Policy for further information on how to transfer.
Residential Addiction Rehab Options
There are two programs offered by the VA for residential substance use rehab: RETREAT and AAC. This option must be recommended by SARP during an inpatient consult. The role of the wards team is minimal and is navigated by the SW team.