Write and sign a discharge summary

The discharge summary is the clinician's account of the stay. Signing it completes the discharge tasks, so the patient can be discharged. Each encounter has one summary, with later versions made by amendment.

Write and sign

1. 1Open the patient's encounter and select Discharge Summary, or open Documents → Discharge Summaries and select New.
2. 2Check the Encounter, Disposition (Home, Transferred to another facility, Rehabilitation / long-term care, Left against medical advice, Death or Other) and Condition At Discharge.
3. 3Enter the Principal Diagnosis and any Other Diagnoses.
4. 4Write the Presenting Complaint and the Hospital Course. Add Procedures Performed and Key Investigations.
5. 5Review the Allergies and Discharge Medications that Ventrecs fills in from the record, and any Results Pending at Discharge. Add Medication Changes / Notes.
6. 6Enter the Follow Up Instructions, the Follow Up Date and Follow Up With, patient education, and When to Return / Warning Signs.
7. 7Select Sign. Only a clinician can sign.

Summary states

Good to know

• Principal Diagnosis, Hospital Course and Follow Up Instructions are required.
• The encounter must be active or discharged to sign. A cancelled encounter has no summary.
• To change a signed summary, select Amend. A new draft version is created and the earlier version stays on file as superseded.
• Select Print for the summary and Print Discharge Card for the card given to the patient.
• On the encounter, Discharge Instructions creates the patient-facing instructions: wound care, activity, diet, medicines and emergency return advice, with the interpreter used and the nurse and patient signature.

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