Setting 1: Hospital or ED from where patient is discharged (sends discharge summary to PCP or Care Team).

A patient is discharged from the hospital. Discharge instructions are given to the patient by his nurse or care manager on day of discharge at or a short time before the physical discharge. The instructions may be generic, patient specific, or disease specific depending on the facilitys practices and the patients needs. The patient acknowledges that he has received the instructions from the nurse (verbally, in writing, and/or electronically). The acknowledgement triggers the physical discharge sequence of events and patient transport out of the facility. The discharge instructions are sent to the patient's PCP or Care Team (as the instructions may contain information necessary for the PCP or Care Team to follow up with the patient before the discharge summary is available).

Upon discharge, the discharge summary is prepared within the Hospital EHR system by one of the patients treating clinicians. The actual clinician is dependent on the hospitals workflow and may be a resident, a hospitalist, an advanced practice nurse or the attending physician of record. Once the discharge summary is prepared, it is ready to be reviewed by the attending physician of record (APoR) (if it has not been prepared by the APoR).

The APoR reviews the discharge summary and, once he has approved it, the discharge summary is sent to the PCP. The message may arrive in the PCPs EHR system even before the patient has left the hospital. A copy of the message may be retained in the hospital EHR per the hospitals policies and workflow rules.

NOTE: The Discharge Instructions described above are also part of the discharge summary. If the discharge summary is ready at the time of physical discharge, it is the only document necessary to be sent to the PCP or patient's care team.

Audit logs of the exchange are retained according to the hospital's, PCP's, and any intermediary's policies, procedures, and agreements.

Setting 2: Patient's PCP or Care Team (receives discharge summary from Hospital or ED clinical system).

Discharge summary/instructions are received into the PCP practices EHR system. Patient generally will be known in the EHR system in which case an automated EHR match may occur (for example, if the hospital and PCP systems can share a common patient identifier). Discharge summaries/instructions that are not automatically matched to a patient are reconciled manually, which may include the process of creating a new patient record and registering the patient. Once the discharge summary/instructions have become part of the PCPs EHR system, additional practice variable activities may occur: new tasks may be directed to a front desk staff EHR work queue, as well as to additional staff EHR work queues as appropriate to the practice workflows. Followup/plan of care are managed according to established PCP workflow. For example, upon receiving notification of the patients status, the care manager is now aware that the patient becomes confused when medications are altered and calls the patient to ensure the patient is taking the correct medications post discharge and is following the discharge instructions.

The PCP may review and promote into the EHR the newly reconciled active medications, updated problem lists, new procedures and other discrete data elements. The hospital (or ED) discharge summary/instructions are retained in its entirety as a permanent part of the patients record.

1. Complete the Use Case Diagram, filling in any missing actors and use cases (5pts)
2. Draw an Activity Diagram to support the events as described above (5pts)
3. Draw a Sequence Diagram to describe the messages and order of messages exchanged (5pts)
4. (5pts) In the user story described above, main information exchanged between the Actors is the discharge summary. It contains minimal standard data set and Discharge context relevant data set:

Standard minimal data set: Demographic information, active reconciled medication list (with doses and sig), allergy list, problem list

• Data set relevant to the discharge summary/discharge instructions context: reason for admission, APoR information, follow up/plan of care (e.g., CCD/83 Plan of Care (What patient can do): Forward looking sections (Treatment Plan), treatments, diet, activities, alerts for conditions, future visits (may include several depending on condition) including appointment established. Patient education and information on medication (tied to alerts), disease process, wound care, condition based special considerations, etc.) etc.
• Variable data set relevant to the hospitalization (selected by the clinician who prepared the discharge summary): Procedures during hospitalization, Selected medications administered during hospitalization, Selected vital signs, Emergency contact information, Relevant results, reports, Wound care (if applicable), etc.

Complete a Class to describe the characteristics of the Discharge Summary Document and show the relationship between the Discharge Summary Document, the authoring doctor, and the patient. You can add more classes to the diagram when necessary.