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.
Discharge Progress Note (Part 1/4)
This note combines the old Discharge Part A and Med: Discharge Progress Note. This note includes the patient’s final diagnosis (Principal reason for hospitalization) for the admission. Also include any changes in mental/physical status of the patient, their physical exam, pertinent labs from that day. It also includes any issues that will require follow up by the patient’s PCP (labs, imaging, consults, etc.) , any appointments that the patient needs to schedule on their own. It also includes tobacco, alcohol and substance abuse screening. Make sure you offer your patient appropriate follow up (i.e. SARP) or pharmacotherapy (ex. nicotine patches, naltrexone) if indicated. This note will serve as your progress note of the day of discharge.
Discharge Patient Instructions (Part 2/4)
This note now does NOT have medication reconciliation. This note is now formatted as patient instructions. 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. Please use language that the patient would be able to digest. Their appointments will also automatically pull in. 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.). Please be sure to include the appropriate diet and activity level for the patient.
Discharge Medication Reconciliation
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.
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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.
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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.
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*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.
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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.
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Step 3: 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.
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Please click here for full instructions on specific scenarios (such as work flow for discharges to CLC)
discharge order
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.
discharge summary
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. If your patient is being discharged to a facility, please copy over the med rec as well as any specialty nursing orders (i.e., tube feeding, wound care).
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
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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.