The purpose of this report is to compile relevant client specific information that is commonly used upon discharging a patient after an inpatient stay, transfer to another provider/clinic/unit or can be used to provide medical-related information for a patient.
This report is medically focused because it allows for selection of medications, orders and labs. It is used in conjunction with CalMHSA Discharge Summary which allows for written text. There still exists the Summary of Care and Discharge Summary within SmartCare which is more extensive as it has diagnoses and procedure codes listed. There is also CalMHSA Patient Instructions/ Transfer Summary which this report is not linked with. These documents can be used by users to write in textboxes, but do       not have any medical-related data.Â
The defaulted users that have access to this are those with permission to Medication Rx, Add Medications Prescribed Elsewhere, Add Pharmacies to Rx, Prescriber, IP/CSU/Res, Medical IP/CSU/Res, CalMHSA SysAdmin, Allergies and Flowsheets, and Medical Supervisor.
A client must be selected in order to run this report.
- With a client open, click the Search icon.
- Type Aftercare in the search bar.
- Click to select CalMHSA Client Discharge Medical SummaryÂ
- The report view window will open. Click the show sections menu drop-down and unselect the fields you donât want on the report. Leave all selected to view all fields on the report.
- Note: For field options labeled as 6- DC [Title], these refer to the textboxes of the document âCalMHSA Discharge Summaryâ. This is where you can write any specifics.
- In the Discharge Document field, click the drop-down menu and select the relevant CalMHSA Discharge Summary from the list by Effective Date, Program and Author. Only one discharge summary can be selected at a time. You will only see the options within your CDAG.
- Note: You can also select âno discharge summary was completed.â If that is the case, then the âGeneralâ and âDischarge Planâ sections of the output will be suppressed.
- Click View Report.Â
Client Information & General
- All reports will include the patient name, client ID, and age.
- It will also include if available, the preferred name and pronouns, address, phone, email, and preferred pharmacy
General
- This section is based on the CalMHSA Discharge Summary document that was selected. The author of that document is presumed to be the provider, along with program, program address, program location, program phone number, and effective date of the document. If âNo Discharge Summary Completedâ is selected as the parameter then this section will not appear.
Last Vitals
This section will demonstrate the last three vitals that have been obtained for the patient.
Medication Changes
- This section will demonstrate the following changes that have been made to Medication Rx within the last 24 hours. If there are any medications that have changed > 24 hours that users wish to highlight, this will have to be done manually in the âCalMHSA Discharge Summaryâ within one of the text boxes such as âDischarge Planâ textbox.
- Any medication that has been discontinued will be denoted by âĂâ in red. Any medication which has been added, and/or a change in strength, will be denoted with a â&â in blue. Any medication that has new instructions and/or changes to the order sig will be denoted with a âiâ in blue. If there are no changes, there will be no icon.
Medications Ordered
In the Medication Ordered Section, this shows only current and active medications in Medication Rx Module. The icons will show up if:
- Green check mark =Successful transmission to pharmacy
- Red cross out = Error (e.g. rejection of transaction, prescription was not sent/received, unable to authorize)
- Blue paper icon = Printed/Faxed prescriptions
- Blue question mark icon = In queue/pending or other
Medications-Reported
In the Medications Reported section, this shows only current and active medications that are reported by client or other external providers within Medication Rx Module.Â
Current Orders-Non Medications
In the Current Orders Non- Medication section, this includes any “Active” or “Sent to Lab” orders within Client Orders with any type of order that is non-medication.
Lab Results
In the Lab Result section, this will show you any lab results for the client within the last 6 months. For any lab results in the gray section of any column, there will appear an “R” if it has been reviewed. For any lab value that has a ” * ” , if you hover over, it will show any lab vendor notes about that test or test result. For any lab value that is outside of the acceptable range, this will be highlighted in red. For more comprehensive lab results, one can use the “CalMHSA Cumulative Lab Flowsheet Report [Client]“.
Sections from CalMHSA Discharge Summary Document
If you want to create a new CalMHSA Discharge Summary Document, then please follow these instructions. Any saved text within these textboxes, and if selected in the filter parameters, will push into this report.
- DC Episode Summary
- DC Reason
- DC Mental Status
- DC Prognosis
- DC StrengthsÂ
- DC Other Information
Future Appointments
In the Future Appointments section, this a compiled list of any future appointments that a client has scheduled within a CDAG.
