A Discharge Summary is a document that pulls information from different places in the client’s chart.
- Make sure you have the client open. Click the Search icon.
- Type in “Discharge Summary” in the search bar.
- Click on “Discharge Summary (Client)” in the search results.
- Select your program from the dropdown menu.
- Click OK.
- This opens the Summary of Care document. Enter the parameters for your summary of care. If your program has specific requirements for the Discharge Summary, make sure to include all the required elements.
- Click Sign. This produces a PDF, which includes information from the client’s chart.
The PDF will automatically pull in the most recent diagnosis document from your program, the client’s current medication list, and the client’s current problem list. Other identifying client information will also be pulled automatically into the pdf