discharges
Discharging a patient is one of the most important parts of a patient's hospital stay. A thorough and accurate discharge can set up them up for success outside of the hospital, preventing post-hospitalization complications and readmissions. The process of discharging a patient from the VA is as follows.
PART 1: Discharge Progress Note
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This note combines the old Discharge Part A and Med: Discharge Progress Note.
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This note includes the patient’s final diagnosis (Principal reason for hospitalization) for the admission, any changes in mental/physical status of the patient, their physical exam, pertinent labs from that day & any issues that will require follow up by the patient’s PCP (labs, imaging, consults, etc.) including any appointments that the patient needs to schedule on their own.
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It also includes tobacco, alcohol and substance abuse screening.
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Tobacco use → Offer cessation meds + cessation clinic referral
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AUDIT‑C score >5 on admission screening → Offer alcohol cessation meds + outpatient follow-up
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Active Opioid Use Disorder, not on medication-assisted therapy (MAT) → Offer suboxone, place SARP (SUD Outpt Grp) consult prior to discharge. If the patient refused MAT, prescribe nasal Narcan at discharge
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Part 2: Discharge Patient Instructions
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When you open this note, you will get a prompt that says the date of discharge and where the patient was discharged too. There will also be a section that will prompt to say why the patient was admitted and how they were treated.
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Use simple language that patients understand.
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Their appointments will also automatically pull in.
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There is also a section for you to write any work up the patient should get done as an outpatient (echo, labs work, imaging, etc.).
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Please be sure to include the appropriate diet and activity level for the patient.
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This note now does NOT have medication reconciliation. Do not include medication dosages here; all medication details are listed in the Discharge Medication Reconciliation note below.
Part 3: Discharge Medication Reconciliation
Step 1: Reconcile & Order Medications
1) Review the Medication Reconciliation report (Reports > Health Summary > Medication Reconciliation). This report lists inpatient, outpatient, remote (from another VA), and non-VA medications, alphabetically. This will allow you to identify new medications, dosage changes, and items requiring discontinuation. It’s helpful to copy this into a document for reference as you work through the process of reconciling the patient’s medications.
TIP: Check medications marked “EXPIRED” at the report's end. Confirm with the patient that he/she is still taking the medication, then renew/discontinue it at discharge.
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.
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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.
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Let the nurse know so they can call pharmacy to make sure the medications are handed to the patient prior to discharge.
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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 EPCS number, which can be obtained by calling the outpatient pharmacy or from one of the chiefs.
Step 2: Create the note - Discharge Medication Reconciliation.
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.
Avoid last-minute changes to a patient’s discharge medications unless essential. If changes are needed, update the Discharge Medication Reconciliation note if already signed.
* Please notify your team pharmacist of discharges 24 hours prior to planned discharged or by noon for same-day discharges. They can work with you to complete Discharge Medication Reconciliation.
discharge order
When Part 1-3 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 (i.e - ETA of the patient's ride or if you are waiting for the outpatient medications to be filled).
Part 4: Complete Discharge Hospital Summary
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Must be completed prior to discharge to short-term rehab or long-term care
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Complete within 48 hours if discharged home, but ideally on day of discharge
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Please make sure you include a section below your problem list that includes things for the PCP to follow up/act on as an outpatient
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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.
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If your patient is being discharged to a facility, please include any specialty nursing orders (i.e., tube feeding, wound care).
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IMPORTANT: Do not list medication details in the Discharge Summary (ex: medication doses). Reasoning for changes may be included, but specific details must only be listed in the Discharge Medication Reconciliation 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:
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Click "Note" tab >>"New Note">> type "Beneficiary" >>select "Beneficiary Travel (BT)"
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Special Mode Transport: Yes, (insert reason for needing BT note ie. severe deconditioning)
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Inter-facility Transport: Yes, (insert level of care of transport ie. BLS, ACLS)
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Day to Commence: Today >> length of time: 1 year
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Fill in: To and From Addresses (one should be the DC VA address)
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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 "Summary of Death" note, Discharge Summary, and Discharge order, but do not need to complete Part A or Part B. You or the nurse should contact Decedent Affairs at x58404 if between hours of 7:30am to 4pm or AOD at x58236 if after hours.The office of Decedent Affairs will contact family and provide 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 Discharge Progress note (Part 1), Discharge instructions (Part 2), Discharge Medication reconciliation and Discharge Summary. See the Transfer Policy for further information on how to transfer.