Discharge Instructions
One of the key ways Shepherd saves you time is by automating discharge instructions. Discharge instructions are associated with products, services, medications, and diagnoses, and whenever they're added to a patient's treatment plan or medical record, they'll automatically populate in the record.
Since discharge instructions need to be added to specific items before they can populate onto a patient's record, this article is broken down into three sections:
Adding discharge instructions for products/diagnoses
At a high level, you can add discharge instructions to:
Adding Discharge Instructions to Products/Services
To navigate to ‘Products’ from your dashboard, click ‘Admin’ and then ‘Products.’
To see, add, or edit discharge instructions for a specific product, go to the ‘Products’ section of Admin. Once you’re there, you can search for the product in the upper left corner.
If you only want to see the discharge instructions, click the view icon (the eye) on the right side of the screen under ‘Actions.’ If you want to add or edit discharge instructions, click on the product. This will open the product up and you’ll be able to see all the fields you can edit. Scroll to the bottom to see the discharge instructions.
Note: If you’re adding discharge instructions, be sure the ‘Discharge Instructions’ checkbox is selected.
The discharge instruction box is freeform, meaning you can change/reformat just about everything inside. You can change font size/color, change the paragraph formatting, and even add images.
Adding Discharge Instructions to Diagnoses
To navigate to ‘Diagnoses’ from the clinic dashboard, click ‘Admin’ and then ‘Diagnoses.’
To see, add, or edit discharge instructions for a specific diagnosis, go to the ‘Diagnoses’ section of Admin. Once you’re there, you can search for the diagnosis in the upper left corner.
If you only want to see the discharge instructions, click the view icon (the eye) on the right side of the screen under ‘Actions.’ If you want to add or edit discharge instructions, click on the diagnosis. Once you’re inside the diagnosis’ internal information, scroll to the bottom to see the discharge instructions.
The discharge instruction box is freeform, meaning you can change/reformat just about everything inside. You can change font size/color, change the paragraph formatting, and even add images.
Populating discharge instructions in medical records
Because discharge instructions populate every time you administer their associated treatment/medication/product, there are a few places you can get them to automatically populate in the SOAP. These are:
You can also manually add discharge instructions.
From a Diagnosis
Giving the patient a diagnosis is done in the ‘Assessment’ section of the Patient SOAP. To navigate there, open the patient’s SOAP and click the ‘A.’
Once you’re in the ‘Assessment’ section of the patient’s SOAP, you’ll need to add a diagnosis. To do that, start typing into the ‘Diagnosis’ box. Once the appropriate diagnosis has populated, click it to add it to the record. This will populate any associated discharge instructions.
Note: changing/removing the diagnosis will remove the associated discharge instructions.
From a Product, Service, or Treatment
Administering products, services, and treatments is all done in the same section of the patient’s SOAP: the ‘Plan’ section. To navigate to the ‘Plan’ section, open the patient’s SOAP and click the ‘P.’
Once you’re inside the ‘Plan’ section, go to the ‘Order Treatments’ box. From there, search for and select the treatments you want to administer, and once you’ve selected them all, click the ‘Add’ button to the right of the search bar.
The treatment(s) will populate below, but to populate the discharge instructions, you need to administer the treatment(s). You can do that one of two ways: by clicking on the ‘Administer Treatment’ icon or by clicking the ‘Order Treatments’ button and selecting either ‘Order Treatments’ or ‘Administer Treatments’ (which administers all treatments at once).
From a Prescription
Writing a prescription for a patient can be done in a few ways, but since discharge instructions live in a patient’s medical record, the best way to see them would be by going through a patient’s SOAP. To get there, open a patient’s SOAP and click the ‘Rx.’
Once you’re in the prescription section of the patient’s medical record, click ‘Add New’ in the upper right to add a prescription to their medical record.
When the new prescription screen appears, fill it out with a medication that has discharge instructions attached to it. After all the quantities, etc. have been filled out, click ‘Save.’
Adding Discharge Instructions Manually
From the discharge instructions section of a patient’s SOAP (the ‘D’ in the SOAP bar), click the ‘Add New’ Button on the sight side of the screen in the box labeled ‘Discharge Instructions.’
This will open a new discharge instruction text field that’s freeform and able to be formatted however you like (i.e. with colors, fonts, etc.).
You’re also able to add images, meaning this is a great spot for before and after photos for services like teeth cleaning and grooming.
Viewing and editing discharge instructions in a SOAP
Viewing the Discharge Instructions
To see the patient’s discharge instructions, click on the ‘D’ when you’re inside a patient’s SOAP.
When you’re in this section of the SOAP, you’re able to:
Viewing/Editing Pre-populated Discharge Instructions
Any pre-populated discharge instructions will appear in full when this page is open. To edit them, click the ‘Edit’ button in the upper right corner of the box with the treatment/prescriptions’s name.
You can also delete a discharge instruction by clicking the red ‘Delete’ button.
Tip: you can drag and drop discharge instructions from this tab if you want them in a different order.
Emailing, Downloading, and Printing Discharge Instructions
Different appointments require giving different levels of instructions to clients, so you can choose when and how to send discharge instructions to match the client's needs.
So, depending on the situation, if you’d like to send the discharge instructions to a client, you’re able to do that through the three icons on the right side of the page.
To email: choose the paper airplane icon
To download: choose the icon with the down arrow
To print: choose the icon with the printer