9+ Discharge Summary Templates - PDF, DOC | Free & Premium Templates

 

discharge summary outline

Discharge summary template is usually seen in hospital setting when the patient is near for release in the hospital and requested a medical evaluation templates of all the procedures and treatment done to him/her over the course of the stay in the hospital. This is done by the physician in charge to the patient and can be used for many reasons like insurance claims or for medical research. DISCHARGE INSTRUCTIONS: You must list them out, everything you checked or wrote on the discharge form– do not say “as listed in the medical record.” PENDING LABS: List all labs that are pending at the time of dictation. Labs may have come back between discharge and when you dictate the summary, so provide that information if it is available. Feb 08,  · An essential part of this process is the documentation of a discharge summary. A discharge summary is a clinical report prepared by a health professional at the conclusion of a hospital stay or series of treatments. It is often the primary mode of communication between the hospital care team and aftercare providers/5(21).


Sample Discharge Summary - 10+ Documents In PDF, Word


Posted by Saleem Kamalodeen Documentation. Discharging patients from a hospital is a complex task, discharge summary outline. An essential part of this process is discharge summary outline documentation of a discharge summary. A discharge summary is a clinical report prepared by a health professional at the conclusion of a hospital stay or series of treatments.

It is often the primary mode of communication between the hospital care team and aftercare providers. Delays in the completion of the discharge summary are associated with higher rates of readmission, discharge summary outline, highlighting the importance of successful transmission of this document in a timely fashion.

It gives a detailed description of each section that may be included in a typical discharge summary. Each section illustrates key pieces of information that should be included and aims to explain the rationale behind each part of the document.

In practice, each summary is adapted to the clinical context, discharge summary outline. As such, not all information included in this guide is relevant and needs to be mentioned discharge summary outline each discharge summary.

This section should be completed with the details of the General Practitioner with whom the patient is registered:, discharge summary outline. If no diagnosis was confirmed, use the presenting complaint and explain no cause was identified:. Be as specific as possible when documenting diagnoses.

Some examples of diagnoses for which you should include specific details include:. Explain how the patient was managed during their hospital stay and include any long term management that has been initiated :. This section must include all operations or procedures that the patient underwent:.

Discharge summary outline details of the current discharge summary outline to manage the patient and their condition s after discharge from hospital:. You should include a list of all medications that the patient is currently takingincluding:.

For each medicationyou should include details regarding the following:. This section should outline any allergies or adverse reactions that the patient experienced. It should be as specific as possible and include the following:.

This section includes personal information about the healthcare provider completing the discharge summary:. This section identifies any assessment scales used when clinically evaluating the patient. Some examples of assessment scales commonly used include:. This section discharge summary outline the care of the patient from a legal perspective. Some examples of the types of information it may include are shown below. This section illustrates if the patient poses a risk to themselves, for example, suicide, overdose, self-harm, self-neglect.

Also include if the patient is a risk to others, including professionals or any third party. Standards for the clinical structure and content of patient records [Internet]. Available from: [LINK]. UpToDate [Internet]. This site uses functional cookies and external scripts to improve your experience.

Which cookies and scripts are used and how they impact your visit is specified on the left. You may change your settings at any time. Your choices will not impact your visit. NOTE: These settings will only apply to the browser and device you are currently using. We use Discharge summary outline Adsense, which serves personalised advertisements to users based on their browsing activity.

The revenue we generate from these adverts allows us to keep the website free. Table of Contents. Clinical examination revealed reduced breath sounds and dullness to percussion in both lung bases. There was also a significant degree of lower limb oedema extending up to the mid-thigh bilaterally.

A chest x-ray demonstrated bilateral pleural effusions, with evidence of upper lobe diversion. We will write to you with the results. She was then weaned off oxygen and commenced on regular oral furosemide 40mg OD which is to be continued after discharge. After review from our social worker and occupational therapist, we have arranged a once daily care package to assist Mrs Smith with her activities of daily living.

As a result, we have started you on a water tablet called Furosemide, which should help to keep fluid from building up in your legs and lungs. You should continue to take the Furosemide tablet as prescribed, however, if you become unwell, you should see your GP as this tablet can potentially damage your kidneys if you become dehydrated. We plan to review you in 6 weeks time, in the Cardiology Outpatient Clinic and we will send your appointment details out in the post.

We have also discharge summary outline your GP to take some discharge summary outline tests to check your kidney function in around 2 weeks time. In the meantime, should you have any concerns or questions, you should see your GP. Transport arrangements e. References 1. Available from: [LINK] 2. About The Author. Related Posts. Chiari Malformations NeurologicalNeurologyNeurosurgery. This site uses cookies to provide support and relevant advertisements.

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How to Write a Discharge Summary | Discharge Letter | Geeky Medics

 

discharge summary outline

 

Discharge Summary ¾ The Horizon Profile discharge section (Discharge Information and Discharge Summary) must be completed regardless of the type of discharge (planned or unplanned.) ¾ More details regarding discharging the patient can be found in the Discharge/Transfer of Patient policy located on the Internal Home Care. HOW TO: Discharge Summary Outline. A discharge summary is a note briefly describing the course of treatment a patient has received at hospital while under your service’s care. It includes: why the patient came in, Past Medical/Surgical History, Admission Diagnosis and Discharge Diagnosis (these can be different), Course of treatment in. The Discharge Summary MUST be documented within a 24 hr period of discharge, or at the time of discharge from the hospital if the patient is either being transferred to another facility. All intern DC summaries must be printed out and reviewed personally with the hospitalist attending PRIOR to the intern e-signing the document.