By Pattie Boast and Cathy Potts

After providing patients with simpler, more efficient discharge instructions, the Department of Veterans Affairs Medical Center in Oregon decreased costly readmissions.

A few years ago, the Department of Veterans Affairs Medical Center (PVAMC) at Portland, Ore., was experiencing about 4.1 readmissions for every 1,000 outpatient procedures. By using 140 unique sets of automated discharge instructions, PVAMC has reduced its 14-day readmission rate to about 1.5 for every 1,000 outpatient procedures.

Four Steps to Compiling Discharge Instructions

A team was formed to create a system in which automated patient- and procedure-specific discharge materials could be compiled. This end was accomplished by a four-step process.

First, a nurse was appointed for each clinical specialty to spearhead the project. Duties included identifying the outpatient procedures most frequently performed within the specialty, and then creating draft instructions for each of those procedures.

Second, each section chief was asked to review and approve the draft instruction sets.

Next, the instruction sets were submitted for formal review by the PVAMC Forms Committee. At this point in the process, the instructions were presented in a standard format, identified by procedure.

Last, all approved instruction sets were imported into PVAMC's automated informed-consent application (AICA). Once imported, prompts were added to the documents to help obtain desired information, as well as patient signatures.

A More Patient-Specific Process

PVAMC surgeons now choose an appropriate postoperative care plan for their patients from the order entry module in the medical center's electronic health record (EHR). Nursing staff retrieve the order and create the discharge instructions with the AICA. Through a combination of checkboxes and free-form fields, providers are prompted to document:

  • Dosage directions for any medications to be taken upon discharge
  • The date when it is safe to resume any medications taken routinely, such as aspirin, therapy, or anticoagulant drugs
  • Pain medications received during the procedure
  • Information about the proper use of any medical equipment required after discharge dates of follow-up appointments
  • Other relevant details

Completed instructions are printed and handed to the patient and also posted to the EHR through its integration with the AICA. A note indicating that the patient had received a copy of the discharge instructions is automatically saved within the patient's electronic chart. In addition, imported provider lists allow the name of the physician responsible for care to be clearly identified on the discharge instruction sheets.

Pattie Boast is a program specialist, operative care division, Veterans Affairs Medical Center, Portland, Ore. (

Cathy Potts is a clinical applications coordinator, Veterans Affairs Medical Center (

This article is excerpted from a longer, more detailed case study by the authors, "Connecting Cost and Quality Through Automated Discharge Instructions," which appears in the August 2011 issue of hfm. (After Sept. 30, 2011, this issue of hfm will only be available to HFMA members.)

Publication Date: Thursday, August 18, 2011