Document Discharge Summary

Use the Discharge Summary (BH) template to close and discharge the client from outpatient program services.

1. Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates.
   The Select Template window opens.
2. On the Medical Records tab, select All.
3. Select Discharge Summary (BH), and then select OK.
   The Discharge Summary (BH) template opens.

   

4. Select a program, and then select a discharge status.
   If you select Others, select an appropriate status from the configured list.
5. Select a reason for discharge from the configured list.
6. In the Assessment/Diagnosis panel, do the following.
   • Document the patient's active diagnosis and assessment details.
   • Select the WHODAS 2.0 link to complete the questionnaire about the patient's challenges due to health conditions.
7. Optional: Select the necessary link to document an assessment or a care coordination, or launch a configured questionnaire.
8. In the Summary of Services panel, document the treatment details, participation details, and discharge goals status.
   Note: You can select your saved phrases or select Copy Forward to enter your details. You can also select the Quick Needs and Goals (BH) link to resolve patient needs and update program goals and objectives.
9. In the Support Resources panel, document the resource details such as name, role, and contact details.
   Note: You can select the Include Support Resources on Document checkbox to print the details in the generated document.
10. In the Post Discharge Details and Risks panel, document the patient's post-discharge support details, current risk assessment details, substance usage details, and the destination address details.
11. In the Discharge Plan panel, document the patient's active medications and discharge plans, and instructions.
12. In the Signature (Tasking Supervisor/Staff for review and signoff panel, document the required signature details for the attestation.
13. Optional: To close the selected program for the patient, do the following:
    1. Select the Close Program checkbox.
       Note: Selecting the checkbox is a permanent action and cannot be undone.
    2. In the confirmation window, select Yes to discontinue and change the status of all associated goals, objectives, and interventions to Discontinued with the date of discontinuation as the encounter date.
       The other fields are updated automatically, and the duration is calculated based on the program's open and closed dates.
14. Select the last service date.
15. Select Save from the top menu bar, and then select Generate Document.