Admission/Transfer/Discharge Process Checklist eCare Admission Assessment Process 1. From the Medication List, select Medication History from the left side of the window. 2. Review/Update each section of the Medication History with your patient. Note: Documented Medications by Hx AND Prescriptions with = Home Medications 3. Review compliance information added by nursing. 4. Right click and select Cancel/DC or Complete (Ex. Complete short term therapies and Cancel/DC medications the patient is no longer taking). 5. Add any new Home Medications to the Documented Medications by Hx section Important: You must change the “Type” field to Documented Medications by Hx to add a medication to the Documented Medications by Hx section of the Medication List. 6. Print the Medication Recon on Admission Report from the Task menu item. 7. Complete the Medication Recon on Admission Report. NOTE: This becomes your Inpatient Medication Orders that are sent to Pharmacy for entry into eCare. 8. Write any non-medication orders on the paper Provider Order Sheet. 9. Place the completed Medication Recon on Admission Report on the patient’s chart for nurse or unit clerk to transmit to Pharmacy. eCare Orders Reconciliation on In-house Transfer Process Different Level of Care Medication Orders Reconciliation 1. Select the Reconciliation button from the Medication List window. 2. Select Transfer. Result: The Order Reconciliation: Transfer window displays. 3. Notice only the Inpatient medications require action. Review each of the Inpatient Medications and decide what action should be taken – Continue or Do Not Continue Non-Medication Orders Reconciliation 1. From the Medication list window, select the Orders tab. 2. Change the display filter to All Active Non-Medications. 3. To select multiple orders that require the same action, hold down the CTRL key and select each order. When all selections are complete, right-click on one of the orders and select Cancel/DC and complete order details. 4. Refresh the window. Remember: No paper report is required. eCare Depart/Discharge Process 1. Click the Depart Button 2. Select the pencil on the Medication Reconciliation bar 3. Review each section of the Order Reconciliation: Discharge Window - Home Medications - Documented Medications by Hx AND Prescriptions with no corresponding inpatient medication order - Continued Home Medications - Documented Medications by Hx AND Prescriptions with corresponding inpatient medication orders - Medications - Inpatient medications not taken prior to admission - IV Solutions - Continuous infusion orders 4. Review compliance information added by nursing. 5. Perform an action on each medication: - Home Medications - Do Not Continue After Discharge, Create New Rx, Continue After Discharge - Continued Home Medications - Do Not Continue After Discharge, Create New Rx, Continue After Discharge - Medications - Inpatient medications default to Do Not Continue After Discharge, but can be changed to Create New Rx, Continue After Discharge - IV Solutions - No reconciliation options 6. Print prescription(s), if appropriate. 7. Enter patient Diagnoses. 8. Generate Patient Education/Follow Up, if appropriate. 9. Create basic discharge instructions for your patient from the Interdisciplinary Discharge Section. 10. Sign/close the Depart/Discharge process. 11. Dictate Discharge Summary. IMPORTANT: If you have followed the process defined above, then you DO NOT have to dictate Home Medications, Diagnoses, Follow up information, Patient Education or Discharge Instructions. You can refer to the electronic Patient Discharge Summary or Clinical Discharge Summary in eCare.
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