How to Complete the Discharge Summary
The Discharge Summary is used for any programs. It’s required for some inpatient programs and SUD outpatient programs. The CalMHSA Discharge Summary uses CalAIM principles to provide narrative text boxes […]
How to Complete the Personal Effects Inventory at Discharge
The PEI at admission represents a record of belongings kept by the organization, as well as a record of belongings returned to the client during their admission. It is later […]
How to Discharge the Client from the Unit and Bed
These steps can be performed from the Bedboard or the Residential/Bed Census page. When performing this action, the client’s status will change to Discharged with relation to the Unit and […]
Nurse: How to Document a Discharge Order
Create a New Order, using the steps under Order Sets. When selecting the Order Set, select Discharge as the Order type. Click the checkbox next to the Discharge order. Complete […]
Prescriber: How to Document a Discharge Order
Create a New Order, using the steps under Order Sets. When selecting the Order Set, select Discharge as the Order type. Click the checkbox next to the Discharge order. Complete […]
Prescribing a Medication with Different Doses and Frequency
If you want to prescribe a medication with different doses during a day (eg morning and evening), then once you select your medication and the strength, then you can add […]
How to Discontinue an Order
Access the order and change the status from Active to Discontinued. You must first have the client open, then click the Search icon. Type “Orders” into the search bar. Click […]
How to Document the Medication Administration Record (MAR)
The MAR stands for Medication Administration Record, but it does not only include Medications. Other items, such as safety checks and follow-ups, are also administered on the MAR. Items are […]
Prescriber: How to Sign and Acknowledge Verbal Order
All verbal orders entered by a nurse will include adding the prescriber as a co-signer. All documents to co-sign, orders or not, will display in the Dashboard. Click the Search […]
How to Change the Client’s Legal Status
A client’s legal status is managed through Legal Status orders. To change Legal Status, you will modify the existing Legal Status order. With an active client selected, click the Search […]