Codified Admission Diagnoses – ICD-10
A codified diagnosis will be required within ALL Admit Orders, including Power Plans. All providers entering Admission Orders will be impacted by this change as the current “free text” diagnosis.
- A new required tab within admission order allows the ability to either select existing diagnoses or perform a “quick search” and add new diagnoses.
- Diagnoses are “working diagnoses” and do not need to meet ICD-10 specificity for Admit Order.
- Diagnoses will populate your assessment & plan in dynamic documentation.
- Job Aids for Surgery Power Plan workflow:
- Codified Admit Diagnosis – General
- Codified Admit Diagnosis – Ortho-Spine-Neuro
- Codified Admit Diagnosis – Urology
- Codified Admit Diagnosis – CV Surgery
- Codified Admit Diagnosis – ENT
- Codified Admit Diagnosis – General Surgery
- Codified Admit Diagnosis – GYN
Discharge Redesign Project
Developed as a pilot within the Department of Medicine, it is focused on increased provider efficiencies, improved medication reconciliation, enhanced care team collaboration and increased patient and family involvement. PowerChart changes and new workflows are all part of the design.
- Patient Centered Rounds (PCR) MPage.
- Soft-Stop Alert for Re-reconciliation after Discharge Med Rec and Discharge Order completed.
- Soft Stop Alert if Labs/Tests ordered after Discharge Order completed.
- Documentation Workflow – Medical Readiness Goals for Discharge.
- Expanded Quick Orders.
- Anticipated Discharge Date.
- Discharge Med Rec recommendations by Pharmacists for High-Risk Patients.
- PowerChart Admit Workflow/ Documenting History & Physical and Consult Notes
- PowerChart Carbon Copy and Forward for Signature Process
- eQuery Process
Job Aids (NOTE: These do not take the place of the on-line training.)
- Admit Workflow/H&P/Consult Providers Guide
- Critical Care Admit Workflow/H&P Job Aid
- Medical Student H&P/ Progress Note
- Pediatric Admit Workflow/H&P Job Aid
- Powerchart Ambulatory Project: Provider Update
- Responding to CDI Queries
- Therapeutic Substitution in PowerChart
Additional PowerChart Enhancements:
- Goals of Care documentation incorporated into workflow.
- Diagnosis Assistant in consolidated problems to support ICD-10.
- Medication Alert Suppression
Medication History Process