Discharge Documents Discharge Documents
The following topics are discussed on this page. Use the links to jump to the desired area:
Introduction to Discharge Documents
To generate discharge documents
About the Electronic Health Record
The Discharge Documents page allows you to print and manage patient documents during the transition from the facility to home or another facility. You can also provide the patient with an electronic copy of their clinical information upon request and their discharge packet at the time of discharge.
To access the Discharge Documents window, use one of the following methods:
(Preferred method) From the Hospital Main page, use the Select Patient field to select the appropriate patient using the drop-down list. Then, click the Discharge Docs button. The Discharge Documents window is displayed.
OR
Click the Discharge Documents button on the Hospital Main page. The Patient Search box is displayed. Begin typing the patient information. See Selecting Patients for additional details on using this feature.
Once the patient is selected, the patient's basic episode information is displayed in the yellow bar at the top of the screen, including: patient name, date of birth, medical record number, visit number, room location, admit date, and patient class.
The Requested On and Received On fields display the current date and time. If different, enter the correct date and time when the patient requested the information.
The Document Section contains a list of the health information available to the patient. Check the boxes of the clinical information/reports you want to provide the patient. If you select Discharge Instructions, a Patient Request check box is displayed. If this a patient-requested document, check the Patient Request box. (This field is essential to tracking patient requested documentation for Meaningful Use reporting.)
Click Generate Document.
The Electronic Health Record displays a list of uploaded and generated EHR documents. This function also provides the ability to generate and transmit the patient summary record (CCDCCR) to other providers and organizations, including the discharge summary, diagnostic test results, problem list, medication list, medication allergy list, immunizations, procedures, and current weight.
Documents are listed with Date generated, Type, File Description, Action, Action By, and Action On information. For each document, you can preview and/or download the document.
For the desired document, click the Preview button, 
, located to the right of the document. The document preview is displayed.
You can jump directly to a specific section of the document by clicking
a heading in the Table of Contents,
which is displayed on the left side of the screen.
For a document in the list, you can download it to
another location. Click the download button, 
, located next to the desired
document. The Opening dialog box is displayed.
Select Save File radio option.
Click Ok. Based on individual settings, the document will be saved to the download location.
In the Electronic Health Record column header, click Upload. The Upload EHR File (CCD/CCR) box is displayed.
In the File to upload field, click the Select button to locate and select the desired document to upload.
In the File Description field, type a description for the uploaded document.
The Password field is used for encrypted files only. If required, enter the appropriate password in this field to import the document.
Click Upload.
In the Electronic Health Record section, click Generate. The Generate EHR File (CCD) box is displayed.
In the Requested On date and time fields, enter the appropriate date that the CCD has been requested.
In the Received On date and time fields, enter the appropriate date that the CCD has been received
In the Reason field, enter the appropriate reason for generating the CCD: Summary of Care or Patient Request.
In the CCD File Description (optional) field, type a description of the upload. As stated, this field is optional.
At the Encrypt check box, check if you wish to encrypt the CCD. If you check this box, an Encryption Key field is enabled. Enter the appropriate password.
Click Generate.
The Personal Health Record sections display statuses and documents that have been sent to the patient's personal health record with HealthVault. Prior to documents being able to be displayed/sent, the facility must have PHR set up in the Maintenance application. Then, the following steps can be performed to activate the individual patient's account process.
This step is done with information provided by the patient, i.e. you have a form with the patient's information or the patient is present. To activate this patient's personal health record, click Register Access. The Register with Microsoft HealthVault window is displayed.
In the Email field, enter the patient's e-mail address. (Instructions will be sent to the patient for accessing HealthVault and creating their HealthVault account.)
In the Identification Question field, use the drop-down list to select a question that will be used to identify the patient when they create their HealthVault account.
In the Identification Answer field, type in the answer to the question identified in step 2. This will also be used when the patient creates their HealthVault account.
Click Register PHR Access. This will activate an e-mail that is sent to the patient with further instructions and a unique identity code. Once the patient has completed the remaining steps and gives permission for Healthland to send documents/information to their personal health record, the Save and Send PHR button is enabled throughout the Centriq applications when information can be sent to the patient's person health record.