Discharge Summaries / Green Sheet
The Discharge Summary / Green Sheet is unique in
that all providers have the ability to edit an existing
note until the time it is signed.
NOTE: Before creating a Discharge Summary /
Green Sheet, access CPOE and designate the inpatient
medications the patient is to continue to take after
discharge. See CPOE and Discharge Medications
on the back page.
To create a new or edit an existing Discharge
Summary/Green Sheet, click
under Create
Notes. By default it opens as a Green Sheet or Brief
Discharge Summary which is used by the nursing
staff to document the patient's discharge instructions.
Document the Green Sheet in the same manner as all
other direct entry notes, moving from tab-to-tab.
Once created, the note is available under the patient’s
Reports Tab under the
link.
WARNING If a patient is to be discharged <48
hours after being admitted, the Brief must be
converted into a Full Discharge Summary and the
Procedures and Discharge Day Services Tabs must
be completed.
To change the Brief into the Full Discharge Summary,
click
Service Tab.
under the
Saved Note Icon - The icon that displays under the
Saved Note column changes based on the "current
state" of the note.
- Brief Discharge Summary Work in
Progress
- Full Discharge Summary Work in
Progress (same icon but larger)
- Brief Discharge Summary that is
Locked. The note is only available to the user
who locked it.
- Full Discharge Summary that is Locked.
The note is only available to the user who
locked it (same icon but larger)
- Brief Discharge Summary that has been
Signed or Finalized. Clicking on this icon
automatically converts the Brief Discharge
Summary into a Work in Progress Full
Discharge Summary.
PROCEDURES, LABS and Present Illness
tabs in the Full Discharge Summary
Procedures tab
 Defaults procedure information documented
in the last signed Progress Note and
procedures created online within the date
range selected.
 Set the Start and End Dates to pull in all
Intermediate and Surgical/Operative
Procedures
Labs tab
 Set the Start and End Dates to pull in all
Labs and Radiology Reports
Present Illness tab
 Pulls in the Present Illness details from the
last signed H&P.
Add an Addendum to a Signed Note
Physicians who have electronically signed a direct
entry note can now add an addendum to the note.
To add an addendum:
1. Open the patient’s record, click the reports tab
and open the report.
2.
If the
button does not display, it
indicates they are not on record as having
electronically signed the report and therefore
are unable to add an addendum.
3. Click the
button.
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. When you do the following window displays.
4.
Enter the addendum in the text field and
click
. The addendum attaches
itself to the bottom of the original
note.
CPOE and Discharge Medications
In the process of documenting the Discharge
Summary / Green Sheet, inpatient medications the
patient is to continue to take after discharge can
be moved from CPOE to WebCIS and reconciled
with the Outpatient Medication list. When
completed, these medications are available in the
Discharge Summary / Green Sheet.
1.
2.
Now that you have "flagged" the Discharge
Medications, return to WebCIS
8. Click
under the
Medications tab. The Discharge Medications
flagged for Home in CPOE Displays on the
right side.
Click the
on the WebCIS navigation
menu.
The patient automatically opens in CPOE.
3. Click
4. From the Home Medications view, click on
ch medication the patient is to be discharged
with.
5. Click
6. Click
7. From the Sign Orders screen, enter your
9. Click the check box for each Medication the
patient will continue to take once discharged.
10. Click
. Then click
.
11. When the Outpatient Medications screen
displays, click the medication description
hyperlink for each medication to validate all of
the parameters (e.g., frequency, quantity) and
update as necessary.
password and click
Outpatient Clinic Notes
Four new Outpatient Clinic Notes are now
available with the option to choose New or
Established.
Select a NEW Note type for the first clinic visit.
For every subsequent visit, select the
corresponding Established Note type. By doing
this, data from the NEW Note is available giving
the user the option to include or exclude this
information.
The New Patient Detailed Clinic Note and the
Outpatient Detailed Consult Note work exactly as
the History and Physical Note and Inpatient
Consult / Ed Note do today, with the following
exception.
Under the Diagnostic Tests tab
 Set the Start and End Dates to pull in all Labs
and Radiology Reports
The New Patient Freeform Clinic Note and New
Outpatient Freeform Consult Note both provide
one General Notes text entry field in which to
document the details of the patient visit.
To include data from the previous note, click
Healthcare Maintenance
Designed to facilitate the monitoring and
treatment of patient specific conditions and to
assist doctors, ensuring that tests and treatments
are timely.
Disease Prevention
The
icon in the Result column indicates test
results are available. To view the results, click on
the icon.
Provides reminders of when a test or procedure is
due for your patient. These reminders are based on
the patient’s age, sex, race and any disease factors
specific to the Specialty.
Disease Management
Each specialty is responsible for determining the
disease groups and levels of disease monitoring for
a given population so that certain test results are
automatically flagged in red when their age or
value exceeds a particular threshold.
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