Discharge Summary/Transfer Summary Document Enhancements, Extended Version

A new Extended Version of the Discharge Summary/Transfer Summary documents are available with Main Office Software version 6294 and Clinical Point of Care version 2681 in the Managed Hosting Environment only. Server based Clinical Software users will not see the enhanced version but may utilize the Discharge Summary/Transfer Summary Enhanced Version in the Main Office Software.
The Extended version has been made available in advance of finalization of the Federal Register proposed rule for Home Health Discharge planning, Discharge Summary/Transfer Summary content requirements.
Upon adding the Discharge Summary record, the option to convert it to a Transfer Summary continues to remain available. Continue to review and complete the dates the Discharge/Transfer Summary covers. Entry of the Date range will be important in utilizing efficient population of the patient history for the document. An additional Check box is available in the upper right corner to utilize the Extended Version. The Extended Version will display additional tabs providing the opportunity to complete the additional content. Each tab provides an option to Import data from the Patient’s Historical Clinical record entered into the software.
The Status tab will import documentation from the Plan of Care to include the patients Functional Limitations, Mental Psychosocial Behavioral status, Allergies and Immunization Status.
The Vitals tab will allow import the patient vital signs documented in the patient’s clinical records for the dates covered by the Discharge or Transfer Summary.
The Wound tab will allow import of wound documentation in the patient’s clinical record for the dates covered by the Discharge or Transfer Summary.
The Meds tab will allow import of the Patients current medications at the time of Discharge or Transfer.
The Illness tab allows documentation of the course of the patients illness. An option is available to import the narrative note from the last or previous Comprehensive Visit assessment.
Consultations tab will allow import of the documentation found in any Communication Notes designated as a Special type, Addition of MD or Physician Referral.
The Labs tab will allow import of the documentation found in any Communication Note designated as Lab/Lab Work.
The Support Tab will allow Import of the documented Supportive Assistance from the Plan of Care.
Orders tab will allow import of all documented Physician Order updates during the dates covered by the Discharge/transfer summary.
The Transition tab allow direct data entry of the Recommendations Instructions and precautions for ongoing care.
The final Tab, Goals will allow import of the Patient goals. After Import, direct data entry of the patient status for each goal is allowed.
The Final print copy of the Discharge Summary will include patient demographics, Code Status, Language Preference, Diagnosis and a Summary of all services received during the dates covered by the Discharge or Transfer summary.