Overview 

ICANotes+ enables you to generate discharge summaries for your clients from the compiled notes. When you compile any notes other than the Clinical Summary and Treatment Plan, you can see an option to create a discharge summary within the compiled notes. The Discharge Summary feature allows you to document information such as care summary, assessments, narratives, discharge instructions, referrals, follow-up instructions, and the care team associated with the clients.

Basic Workflow 

Below outlines the sequential steps involved in utilizing the Discharge Summary feature within ICANotes+.

The practice users will,

1. Configure the Discharge Summary feature in the Settings and Personal Preferences sections.
2. Set up access to the Discharge Summary feature in Roles and Permissions and Caseload Security modules.
3. Compile any of the following notes: Case Management, Complete Evaluation, Couples/Family Therapy, Progress Note, Quick Note, and SOAP Note.
4. Click on the "Create Summary" dropdown located at the top of the compiled notes and choose the "Discharge Summary" option.
5. Three tabs will appear: Care Summary, Discharge Instructions, Compile.
   • Care Summary: Capture medical history, diagnosis, adverse drug reactions, medications, vital signs, SNAP assessment, Multiple Antipsychotics, clinician's narratives.
   • Discharge Instructions: Capture details such as discharge status, type of discharge, etc., from the dropdown. Add custom content if needed, and include referral details.
     
   • Compile: Capture follow up instructions, add care team details, and then compile the discharge summary.
6. Preview overall discharge summary details within the Compile tab.
7. Compile discharge summary and capture electronic signature.
8. Download/Print discharge summary details.
9. Access the Dashboard to navigate to the discharge summary.
10. Access a copy of the discharge summary from the Documents tab in the client's chart and share it with client portal user if desired.

Configure Settings for Discharge Summary

You must first configure the Discharge Summary feature for your practice. 

Navigate to the Settings option on the side bar, click the Note Settings tab from the top, and then select the Note Settings option from the left side bar as shown below. Select the Active checkbox for the Discharge Summary note type.

Navigate to the Personal Preferences section, click the Note Settings tab from the top, and then select the Note Settings option from the left side bar as shown below.

Select the applicable checkboxes for the Discharge Summary note type from the following screen. When you create a discharge summary, you can compile the note for the selected details you have recorded for the clients.

Assign Access on Discharge Summary in Roles and Permissions 

The administrators can allow the authorized users to access the Discharge Summary feature in the Roles and Permissions section. 

Only the authorized users can view, create, or edit discharge summary. In Roles and Permissions, when you create or update a role, you can locate permission for the Discharge Summary.  When you expand the Discharge permission, you can see the following three options:

• View Discharge Summary: Select this checkbox to allow the users only to view the discharge summary details. The users with this role can only view the progress of treatment, they cannot add or edit discharge summary.
• Create Discharge Summary: Select this checkbox to allow the users to create discharge summary. The users with this role will not be able to edit discharge summary.
• Edit Discharge Summary: Select this checkbox to allow the users to edit discharge summary. The users with this role will be able to make the necessary modifications within the discharge summary.

Refer to the following screenshots to assign access in Roles and Permissions.

Assign Access on Discharge Summary in Caseload Security

Depending on the access granted to practice users within the Caseload Security module, the system will enable them to access the Discharge Summary feature for the clients with whom they collaborate as a part of the clinical team.

• All Access: The users with the All Access permission can access all the discharge summaries for the client. In this example (screenshot below), Smith John has a permission to access all the discharge summaries irrespective of being a part of clinical team.

• Clinical Team’s Charts Only: The users with this permission can access discharge summaries where they are either an assigned clinician or a part of the clinical team for the respective client. In this example (screenshot below), Steve Smith has access on the 'Clinical Team's Charts Only' option. This user can access only those discharge summaries where he is either an assigned clinician or a part of the clinical team for the respective client.

• Clinician’s Charts Only: The users with this permission can only access the discharge summaries where they are assigned clinicians. They cannot see any other discharge summaries for the specific client. In this example (screenshot below), Sam Jonas has access on the 'Clinician's Charts Only' option. This user can only access the discharge summaries where he is an assigned clinician.

Navigate to Discharge Summary from the Notes 

When you compile any of these notes (Case Management, Complete Evaluation, Couples/Family Therapy, Progress Note, Quick Note, and SOAP Note), you can locate the Create Summary dropdown on the top of your compiled notes.

Click on the Create Summary drop down and select the Discharge Summary option as shown below.

On selecting the Discharge Summary option, you will be redirected to the following screen to capture discharge summary details.

Capture Details in Discharge Summary 

When you create a discharge summary, you can locate the following three tabs as shown in the screen below. 

• Care Summary
• Discharge Instructions
• Compile

Details Within Care Summary Tab 

Within the Care Summary tab, you can capture the following details:

• Medical History
• Diagnosis
• Adverse Drug Reactions
• Medications
• Vital Signs

When you select Yes option, the details captured within the system appears in the preview pane on the right side.

When you enter the narrative in the Clinician's Narrative field, the narratives appear in the preview pane on the right side as shown below:

The users can conduct the following assessments within the Care Summary tab:

• • • SNAP assessment
    • Multiple Antipsychotics

When the assessments are recorded, they appear in the preview pane on the right side as shown below:

Clicking on the SNAP Assessment button opens the following screen to capture the SNAP assessment details.

Details Within Discharge Instructions Tab 

Within the Discharge Instructions tab, you can select the following details.

• Discharge Status
• Type of Discharge
• Conditions on Discharge
• Prognosis
• Disposition
• Medication Instructions
• Consent
• Physical Level
• Dietary Instructions
• Emergency Contact

Additionally, you can select the following checkboxes for the copy of instructions requested by clients:

• Client Request Copy of Instructions: Select this checkbox if the client has requested copy of instructions.
• Client Given Copy of Instructions: Select this checkbox if you have provided the copy of instructions to the client.

When you select the discharge instructions, they appear in the Preview pane on the right side. Refer to the screenshot below.

You can also record referral details in the Discharge Instructions tab. The information about the referral details is explained separately in this article.

Ability to Add Referrals 

Within the Discharge Instructions tab, locate the Add Referrals section after the discharge instructions as shown below.

Select the desired name from the dropdown. If the desired referral doesn't appear in the list, click the Add New Referral link to add a new referral entry.

Note: When you expand the Referred To dropdown, it displays only the medical related contacts.

When adding a new referral entry, select the Medical option in the Type dropdown as shown in the screen below.

Add Custom Content in Discharge Instructions

Within the Discharge Instructions tab, you can select the desired option from the dropdown fields. However, if the desired option doesn't appear in the list, you can create your own custom content for each field in the Discharge Instructions tab. Expand the dropdown and click the Add/Edit Custom Content link as shown in the screen below.  

When you click the Add/Edit Custom Content link, it opens the Add Custom Content screen as shown below.

Perform the following steps:

1. Enter the status, custom content and click the Add button.
2. Once you add custom content, click Save.
3. To add new custom content, click the Add New button from top.

When you add custom content, it appears as shown in the screen below.

• To make any modifications to the custom content, click Edit.
• To delete the custom content, click Delete.

Details Within Compile Tab 

In the Compile tab, you can record the follow up instructions and add care team members.

Locate the Follow up Instructions field in the Compile tab. When you enter follow up instructions, they appear in the preview pane on the right side as shown in the screen below.

Add Care Team Members 

In the Compile tab, you can locate the list of care team members as shown in the screen below. Click the Add Care Team button to add care team members.

When you click on the Add Care Team button, it opens the Manage Members screen as shown below. You can view a list of all practice users on this screen. If you want to add a new entry as a care team member, click the Create and Add to Team link as highlighted in the screen below.

On clicking the Create and Add to Team link, the Create New Contact screen appears as shown below to add care team member's details.

Preview for Discharge Summary

When you capture details within the Care Summary, Discharge Instructions, and Compile tabs, they appear in the preview pane on the right side as shown in the screen below.

You can view the following details in the preview pane: 

• Date of Admission
• Date of Discharge
• Medical History
• Diagnosis
• Adverse Drug Reactions
• Medications
• Vital Signs
• SNAP assessment
• Multiple Antipsychotic
• Clinician's Narrative
• Discharge Status
• Type of Discharge
• Conditions on Discharge
• Prognosis
• Disposition
• Medication Instructions
• Consent
• Physical Level
• Dietary Instructions
• Emergency Contact
• Follow up Instructions

Compile and Preview Discharge Summary

Once you capture the care summary and discharge instructions, you can compile the discharge summary by clicking on the Compile and Preview button with the Compile tab as shown in the screen below:

The compiled discharge summary appears as shown in the screen below. You can download or print the discharge summary by clicking the Download/Print buttons from the top right corner of compiled discharge summary.

When you capture electronic signature for the compiled discharge summary, it appears as highlighted in the screen below:

Access Dashboard to Navigate to Discharge Summary

Once you compile the discharge summary, it can also be accessed from the Dashboard. 

Locate all the discharge summaries on the Dashboard as highlighted in the screen below:

Access Documents Tab to Share Discharge Summary with Client Portal Users

You can also access the Documents tab in the client's chart to view the compiled discharge summary. If you want to share the discharge summary with client portal users, you can click on the three dots on the extreme right side and click on the Share option as highlighted in the screen below: