How to Complete the Discharge Summary
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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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 […]