Discharge & records

Each admission's discharge summary and the records room (Discharge & medical records add-on): the ICD-10 diagnoses, the course in hospital, the medicines to take home, the follow-up and when to come back at once, signed by the doctor and then kept as written, with addenda for later findings; and each file's way through the records room, received, checked, coded and lent out and back. Open only to roles with "Can open patient records".

Steps

  1. Open Discharge & records and press New summary. Pick the patient's bed (the IP number, name, doctor and admission day fill in) or type them, choose the discharge type and the time, and start it.
  2. Write the diagnoses with their ICD-10 codes (the first is the primary one), the course in hospital, the condition at discharge, the medicines, the follow-up day and when to come back at once. A referral needs the hospital it went to; a death needs the cause. Save draft as you go.
  3. Press Sign the summary. It needs a diagnosis, the course and (but for a death) the emergency advice, and is stamped with your name and the time. After that it never changes: add a later finding as an addendum.
  4. In the records room press File received when the file arrives, tick the consent forms and the orders, then Mark coded. Lend the file to a doctor, an audit or an insurer and press File returned when it is back. The Records room tab lists every file by stage.

Tips

  • A file is late when it is not in the records room within 24 hours of the discharge. The average hours to the records room shows how fast the wards send their files.
  • A file is coded only once the summary is signed and the file received. Each record is kept ten years after the discharge; summaries are never deleted.
  • Switch on "Can open patient records" for the doctors' and records staff's role in Users → RBAC. Each summary's reads and changes go to the patient's access log, and StartAI never reads the summaries.

In the app, press F1 or ? on this screen to open this guide next to your work.

This guide belongs to the Discharge & medical records module. Learn more

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