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Clinical Discharge & Medication Reconciliation

This section describes the clinical, pharmaceutical, and administrative protocols for executing safe patient discharges, performing medication reconciliation, closing inpatient encounters, and releasing hospital beds.

  • Authorized Roles: Attending Doctor, Ward Nurse, Receptionist / Admission Clerk, Billing Officer.
  • Module Identifier: Module 09 (Clinical Discharge).

1. Step-by-Step Safe Discharge Workflow​

graph LR
    A[1. Review All Diagnostic Results] --> B[2. Author Discharge Summary]
    B --> C[3. Reconcile Discharge Meds]
    C --> D[4. Nurse Discharge Checklist]
    D --> E[5. Confirm Bed Release & Billing]

Step 1: Outstanding Results Review​

  1. Doctor opens the patient's record in Beds & Wards or Doctor Dashboard.
  2. Navigate to the Results tab and review ALL outstanding laboratory and radiology reports.
  3. Clinical Accountability: The system does NOT prevent discharge with pending results — clinical responsibility for reviewing diagnostic results prior to discharge rests strictly with the Attending Doctor.

Step 2: Structured Clinical Discharge Summary​

  1. Click + Discharge Summary.
  2. Complete all required clinical sections:
    • Primary Final Diagnosis (Coded with ICD-10).
    • Secondary Comorbidities & Complications.
    • Hospital Course & Treatment Summary (Key procedures, surgeries, and clinical interventions).
    • Discharge Medications (Reconciled prescription list).
    • Follow-Up Plan & Instructions (Clinic review date, wound care instructions, dietary guidelines).
  3. Enforcement Rule: The system applies a default administrative note if no text is entered — a comprehensive, signed clinical discharge summary is required for every patient.
Clinical Discharge Summary and Medication Reconciliation Interface
Clinical Discharge Summary and Medication Reconciliation Interface🔍 Click to enlarge

Step 3: Medication Reconciliation​

  1. Open the Medication Reconciliation Panel.
  2. Review all medications administered during the inpatient stay against pre-admission regimens.
  3. Explicitly categorize every medication:
    • Continue: Continued at home at specified dose/frequency.
    • Change / Substitute: Dose, route, or agent modified.
    • Stop / Discontinue: Inpatient therapy terminated (e.g., IV antibiotics).
  4. Author electronic take-home prescription and transmit to the outpatient pharmacy.

Step 4: Nursing Discharge Checklist​

  1. Ward Nurse completes the bedside discharge checklist:
    • Patient & caregiver education provided.
    • Written discharge instructions and take-home medications explained.
    • Follow-up clinic date and red-flag return symptoms understood.
    • Indwelling catheters/cannulas removed and wound dressings refreshed.
    • Safe transport arranged.

Step 5: Bed Release & Billing Flagging​

  1. Doctor or Receptionist clicks Confirm Discharge in Beds & Wards.
  2. The bed status transitions to Cleaning (or locks into Terminal Clean Required if patient was flagged with contact/airborne isolation precautions).
  3. The encounter is closed and flagged for final billing invoice generation.
  4. An automated notification is sent to the hospital administration and finance teams.

2. Patient Safety Checkpoint: Pending Results at Discharge​

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IMPORTANT:

Pending Results at Discharge Protocol

  1. The system does NOT block discharge when lab or radiology results are pending.
  2. The Attending Doctor must review all outstanding requests before confirming discharge.
  3. For any result that remains pending at the time of departure:
    • Document the specific test name and a clear clinical follow-up plan in the discharge summary.
    • Explicitly inform the patient that they will be contacted once the result returns.
    • Any result returning post-discharge with a critical finding must trigger immediate contact using the emergency phone number in their Moana record.