delacy clinical information systems electronic discharge...

deLacy Clinical Information SystemsElectronic Discharge Summaries

April 2014Michelle Bear RN

Nurse Unit Manager/ Lead Site Project Co-ordinator

Welcome to deLacy

� deLacy Clinical Information Systems is a health app lication package that has been developed by Emerging Systems for the implementation of electronic health records.

� St Vincent’s Health and Aged Care Australia, have c ommitted to the introduction of fully electronic records throughout all facilities over the next seven years.

� As part of that commitment, Holy Spirit Northside P rivate Hospital, St Vincent’s Brisbane Hospital and St Vincent’s Hospit al Toowoomba have chosen to implement electronic discharge summa ries as the first phase. The primary aim for this phase is to ensure that GPs are provided with timely health care information.

� The use of electronic discharge records will commen ce in May 2014.

Learning Objectives

In this sessions you will learn the following key things:

o Log on and password changes

o Creating a discharge checklist

o Creating a discharge summary

o Completing a nursing discharge assessment

o Creating a pharmacy referral for a medication profile

o Accessing a Dr’s discharge instructions/letter

User Access

Click on the deLacy shortcut button on the intranet page to open the application.You should then see the log on screen displayed.

Log on using your usual username and password. Please note, if you are prompted to change your password while accessing deLacy, it will change your password to all SVHAC applications i.e. Riskman etc.

Patient Lists Screen

Once logged on, the patient lists screen should open to your default ward. If there is no ward list displayed, you will need to select a ward and search for it.

Creating a Discharge Checklist

For routine patient discharges that do not require information to be sent to the GP, a discharge checklist is all that is required. To select this option, click once on a patient, then click on the discharge checklist option in the sidebar menu


Complete the discharge checklist as per the questionnaire. Please note that ticking follow up appointments boxes make the comments fields beside them mandatory.

Once the discharge checklist is completed, remember to click on the save button. 2 copies must be printed, one for the patient and one for the medical record..


To print the document, click on the view button. A PDF document will display. Choose which printer you need to from the drop down list.

Creating a Discharge Summary

You will need to create discharge summaries for those patients requiring more complex discharge plans and/or are needing a medication profile. This is to ensure that the nominated GP gets timely health information relating to the patient’s episode of care.

You can make these summaries as simple or as complex as is needed.To create a discharge summary, click on the patient in the patient list screen and then select discharge from the sidebar menu.


Selecting the discharge option will take you to the discharge summary/referral screenClick on the new button to start a new summary.


You should now be in the discharge summary/referral patient details screen. Most of the patient demographics and nominated GP will have pre-populated into the fields. If there is no GP, it may be that the patient has requested to not send information to the GP. It is imperative that you check with the patient regarding information sharing with a GP to ensure the Privacy Act is not breached. If the patient has no GP details and is happy to share information, you can add in a GP and the data base will automatically select the appropriate contact details.You can also add on alternative contact details for family members. Please ensure that this information is also added to webPAS by ward clerks to provide consistency.


There are five tabs at the top of this screen: • Patient details• Clinical Activity• Results and Meds• Risks and Assessments• Info and Management.

The only mandatory field in the discharge summary is the clinical activity screen. Therefore, if the patient is a routine discharge requiring medication profile only, this is the only screen requiring input. You can then use the info and management screen much like a discharge checklist.


The mandatory fields are the following:• Principal Diagnosis• Summary of stay

Finalising a Discharge Summary

Remember to click on the save button at the end of each page you complete. Once you have finished all the fields you need, save and exit the page you are on.This will take you back to the summary/referrals screen. On this page, located at the top right hand corner, you will find a finalise button. Clicking on this will complete your summary ready for printing. deLacy will then also send a copy of the summary to the nominated GP.

Creating a Nursing Discharge Assessment

For patients transferring to other facilities, a nursing discharge assessment should be completed. It is beneficial for this to be commenced as early in the admission as possible to help facilitate early discharge planning. You can create an assessment either through the discharge summary on the risks and assessments screen:


Or you can create an assessment through the sidebar menu. This was is useful for commencing early discharge planning from admission.


Click and highlight the assessment and then click the select button. This brings you to the assessments screen. Please note that to complete an assessment, all questions must be answered.


You will note all the tabs at the top of the screen. You will need to complete the questions on every page to complete the assessment.


Once completed you will be able to view and print this document separately if required. However, it will be attached to the discharge summary if one is created.

Creating a Pharmacy Referral

All medication profile requests will now be made through this system. In order to request a medication profile, you will need to open a discharge summary for your patient. It is best to try and request a medication profile in advance of your patients discharge where possible.

• Click on a the patient requiring a medication profile

• Select the referrals tab on the side bar menu

• Select referral request on the drop down.

Creating a Pharmacy Referral

Creating A Pharmacy Referral

Note the screen on the previous page. All fields coloured pink are mandatory.If you complete the referral type, the remaining fields should auto-populate.Complete the urgency field with the relevant request.

Click on the save button and you will go to the next screen

Search a Pharmacy Order

You can check on the status of your medication profile request through the patient order search screen.

• Click on the referral search tab on the side bar menu


• Select pharmacy consultation, the date you ordered the profile and the status of the order. • Click on the search button, and the med profile ordered for your patient will display with the

current status.• Once the pharmacist has completed the profile, it should display as completed . The medications

will display in the discharge medications section of the discharge summary.• The pharmacist will still provide a hard copy to the patient • Once you have the medication profile, and the patient is discharging, remember to finalise your

discharge summary to ensure the information is sent to the GP.

Selecting Drs Discharge Letters

• Select the patient you are discharging and then click on the medical tab in the side bar menu


• Select doctor in letter type, Type in the first 3 letters of the VMO surname and click on the arrow beside the box. Once you have the correct VMO, select discharge summary in the category field, then select the relevant letter from the templates list.

• Click on the save button and the letter will appear in the letter record as above.


• Click on the letter in the grid as displayed on the previous page. The template you selected will appear in the text box and is now ready for printing.

• Click on the view button and the PDF version of the discharge letter will display for printing.

delacy clinical information systems electronic discharge...

Documents