# Writing Discharge Summaries

You can enter discharge summaries through CPRS. The document templates and TIU titles that your site can create should make creating these documents much faster and easier.

To write a discharge summary, use these steps:

1. Select the D/C Summ tab.

2. Select New Summary or select Action | New Discharge Summary.

Note: If this visit is undefined, you will be prompted for encounter type and location, clinician, date, and type of visit, such as Ambulatory, Telephone, or Historical.

3. In the Discharge Summary Properties dialog, select the following so that the note may be auto-saved:

a. Discharge Summary Title (e.g., General, SOAP, Warning, etc.). Additional items will appear on the dialog for titles that require entry of a cosigner or an associated consult.

b. If necessary, change the note date by clicking the button next to the date and entering a new date.

c. If necessary, change the note author by selecting the author from the Author drop-down list.

(Note about providers with similar first and last names.)

d. Enter the attending physician.

(Note about providers with similar first and last names.)

e. Click the admission related to this Discharge Summary.

f. Enter any additional information, such as an expected cosigner.

Note: For a Discharge Summary, if a user requires a cosigner (such as a student or other type of clinician), that user's name should not appear in the list of potential cosigners. Also, occasionally a problem occurs if a cosigner's access lapses and they have become "disusered". If this occurs, you can click OK and proceed with that selection or click Cancel and choose another cosigner.

g. Select OK.

4. Create the summary content by doing some or all of the following:

o Type text

o Copy and paste

o Insert templates into the document

a. Click the template drawer if it is not open.

b. Locate the appropriate templates.

c. Double-click the template (You can also drag-and-drop or right-click the template and select Insert Template) and modify as needed.

5. (Optional) When finished entering text, you can right-click in the text area and select Check Spelling and Check Grammar.

6. When complete, decide when you will sign the summary and choose the appropriate option:

o Add to Signature List (To place it with other orders or documents you need to sign for this patient)

o Save Without Signature

o Sign Discharge Summary Now (To sign the summary immediately)

Related topics

Discharge Summaries (overview)

Viewing Discharge Summaries

Document Templates (overview)