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Admissions & Discharges

You must use the Admission Navigator which will take you sequentially through the steps below

All admissions will be placed on the Medicine Admission list by the MAO, along with contact information for the ED provider as well as a 1 line summary of the presenting issue.

Care Plans: Check the FYI tab for a care plan – Most patients will not have one.

Best Practice: Will have patient-specific alerts about VTE prophylaxis and core measures.

Care Everywhere: This is where you can request and review outside records from other EPIC systems. Be sure to press the “update” button if a patient tells you that they were just recently at a local hospital.

Problem List: Very important, one of the few things in EPIC that spans both the inpatient and outpatient contexts. SHOULD BE UPDATED UPON ADMISSION with all active problems. Select a “Principal” problem for this hospitalization. This will help auto-populate your H&P. The Problem List should reflect active issues and History (which populates PMH) acts an archive. For appropriate problems, you can File to History to place them in the PMH. Mark as Reviewed at the bottom Right clicking on a problem in the problem list will display several options, including the ability to quickly add problems to the patient’s Medical History.

Allergies and History: will be imported into your H&P -- Mark as reviewed.

Med Rec: 6 different actions Review Current Orders – may include medications/orders initially signed in the ED. Review Home Medications – YOU NEED TO DO THIS. Correct and remove errors/duplicates, discontinue medications patient no longer taking Mark as Reviewed at the bottom If you are unsure of the medication reconciliation (patient or family unable to provide reliable history), document in H&P and Plan sign-out note. Reconcile Home Medications – this is where you order the home medications you reviewed New Orders – Input new orders and use the Order Sets to complete the full admission process. Proper placement of the ADT1 admission order will populate the patient on the treatment team list placed in the order. ADT1 for all new patients: Enter your name as the Admitting Provider and Attending Provider. Assign patient to the Hospitalist New Admit team. As a general rule of thumb, patients are appropriate for inpatient status if you believe they will be hospitalized for more than 2 midnights; otherwise, select observation status. Review and Sign – complete the orders by signing and finalizing (sign and hold)

H&P Notes: Complete your H&P. If EPIC has been used properly in the steps above, much of your note will be prepopulated except for HPI, exam and A/P. Please use our dot phrase, .HMNOTEHP as this includes many elements which have helped our billing and coding.

Sign Out Note: Use .lmnotesignout in the Plan Note window found on the Patient Overview to provide guidance for the Night provider and the team attending.

Admission process from UNC CH ER to HBR inpatient bed:

  • CH ER provider determines patient appropriate for admission to UNC Hospital Medicine service.
  • ER provider calls MAO to initiate admission process.
  • MAO determines appropriate for hospitalist service at CH or HBR and calls CH admitting hospitalist MD with appropriate information. If appropriate for HBR and beds available, MAO will suggest possible HBR bed placement.
  • CH HM provider sees and admits patient using one-piece flow (of the process described above). If they feel that HBR placement is appropriate, they will discuss with patient at time of evaluation.
  • If the patient agrees to HBR placement, CH provider calls, pages (123-7430), or Epic Chats HBR HM admitter to discuss probable transfer and get acceptance.
  • During admission orders, ADT1 order placed to HBR bed. “Transfer Service”, “Preferred facility” and “Provider team” orders should all reflect proper placement. CH provider alerts MAO to transfer to HBR.
  • MAO calls PLC to arrange transport.
  • Capacity and transportation issues may cause substantial delays in the patient moving to the target facility. Please use the “ED Boarding Process” attached in separate document. Please see process flowsheet below.
  • On patient arrival, HBR provider (or next admitting provider) sees the patient in person to welcome them to facility, evaluate any needs and communicate plan on arrival.

Admission process from UNC HBR to CH floor:

  • HBR ER provider determines patient appropriate for admission to UNC Hospital Medicine service.
  • ER provider calls MAO to initiate admission process.
  • MAO determines appropriate for hospitalist service at CH or HBR and calls HBR admitting hospitalist MD with appropriate information. If unable to obtain services at HBR and appropriate for CH, MAO will suggest CH bed placement.
  • HM provider sees and admits patient using one-piece flow. If they feel that CH placement appropriate, they will discuss with patient at time of evaluation.
  • If patient agrees to CH placement, HBR admitting provider calls or Epic Chats CH admitting provider to alert of admission to CH.
  • During admission orders, ADT1 order placed to CH bed. “Transfer Service”, “Preferred facility” and “Provider team” orders should all reflect proper placement to “Med H New Admit”.
  • MAO calls PLC to arrange transport.
  • Capacity and transportation issues may cause substantial delays in the patient moving to the target facility. Please use the “ED Boarding Process” attached in separate document. Please see process flowsheet below.
  • On patient arrival, CH provider (or next admitting provider) sees the patient in person to welcome them to facility, evaluate any needs and communicate plan on arrival.

Transfer process for inpatients between CH/HBR hospitalist services:

Sending MD should contact MAO to arrange transfer between hospitalist services.

HBR transfer sample script:

“UNC Hospital has a campus in Hillsborough opened in 2015. Our inpatient medicine service has beds there that we use for some of our patients. You will have the same group of physicians and same care there. It does have some advantages such as all private rooms, state of the art therapy rooms and newer facilities although it is 9 miles away north on 86. You need to be admitted to the hospital for your care and I feel you would be an appropriate patient to receive your care at that facility. We will plan to have you transferred to our inpatient service there. There will be no cost for transportation, and I will speak to the physicians there so that they know what they need to do to care for you.”

One-Piece Flow:

In 2 separate QI evaluations of the processes of the Division of Hospital Medicine at UNC Hospital, we found that a “one-piece-flow (OPF) method” (rather than a traditional “batching method”) provided a significant reduction in time required to complete an admission or discharge. It also improved efficiency and enhanced patient safety and quality of care.

In light of these findings, we recommend that all of our providers follow the one-piece flow methodology. OPF is a process by which a patient is taken entirely through a process from initiation to completion without interruption. In these cases, the provider completes the entire admission or discharge for a patient while pages and other distractions are deferred and answered at the completion of the process.

Admissions under OPF: Chart Review through completion of Physical Exam, Order Entry, H&P, and sign-out note are completed without interruption. No non-emergent pages are answered during this process. All pages received during the admission are then returned prior to starting the next admission.

Discharges under OPF: Medication reconciliation and the discharge order are placed in the room during rounding on the day of discharge which improves communication with patient and prevents discharge needs from being unanswered. This process works best when discharge needs have been addressed ahead of time (see below) and when discharge instructions have been prepped prior to the discharge day.

Discharging From the ED:

When called by the Emergency Room for a patient admission, it is appropriate at times to consider discharge to home if the following 3 conditions are met:

  • When the patient has no significant inpatient needs,
  • AND
  • A safe discharge plan is available.
  • AND
  • Appropriate outpatient resources are available for follow-up.

If, after discussion, the ER provider still requests a formal consultation:

  • See the patient promptly
  • Write a consult note with recommendations for care as an outpatient

If the ED does not wish to d/c the patient, it is still appropriate to discharge patient to home rather than admit to the hospital. This can be done by changing your Epic context to Emergency Dept UNCH and using the discharge navigator.

DIscharge from Emergency Department context Tipsheet

Discharge/Readmit to Rehab/Psychiatry:

When patients are discharge from the acute care hospital with plans to enter either Acute Rehabilitation or Psychiatry Inpatient the following steps should be followed:

Discharge is performed as per usual routine with Medication Reconciliation. Medications should be “No Print” as they will not truly be discharged. The key difference is that the actual discharge order placed should be a Discharge Readmit order as seen in the screenshot below.