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discharge summary outline

The discharge summary consists of facility, patient name, date of admission & date of discharge. The person needs to fill all the details available in the form including the condition of the patient during discharge. One can check the sample discharge Summary Report Templates available in . 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. 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).

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T he discharge summary is a vital tool for transferring information between the hospitalist and primary care physician, but it isn't always given the priority it deserves. Too often, research suggests, summaries contain insufficient or unnecessary information and fail to reach the primary care physician in time for the patient's follow-up visit, if they arrive at all.

A review of the literature published in the Feb. In the review of 73 studies, the primary diagnosis was omitted a median of Standardization is one potential solution, and some discharge summary outline including Dr. Yadav at Baystate—are helping their discharge summary outline develop templates for discharge summaries. Experts recommend that community physicians have input into this process. A structured, standard discharge summary form ensures that all the important information is included and allows the receiving physician to more quickly identify how to respond to the patient's hospitalization, said Mark Williams, FACP, chief of the hospital medicine division at Chicago's Northwestern Medical Center and co-author of the JAMA article.

The Joint Commission mandates that discharge summaries contain certain components: reason for hospitalization, significant findings, procedures and treatment provided, patient's discharge condition, discharge summary outline, patient and family instructions, and attending physician's signature. Experts advised keeping summaries short for easy readability— ideally no more than two pages long—and including information that is most relevant for the primary care physician.

Most important to include are the reason for admission, discharge summary outline, medications indicating new, changed, and discontinuedfollow- up plans and appointments, outstanding issues for followup, and results of any tests or lab work pending at time of discharge, discharge summary outline, said Jeffrey Greenwald, MD, a hospitalist and director of the hospital medicine unit at Boston Medical Center, discharge summary outline.

His hospital started using a template several years ago, discharge summary outline. The NQF, in its Safe Practice 11, recommends that a discharge summary include, at minimum, the discharge summary outline. Unfortunately, there is no uniform definition of significant findings.

Although some might interpret it to mean only abnormal results, Dr. Yadav does not recommend always limiting the summary to abnormal findings. For instance, discharge summary outline, not to mention that a mass was benign could lead to repeated testing. Be specific about imaging and other tests, Dr.

Yadav discharge summary outline. Thomas Bodenheimer, FACP, an internist affiliated with the University of California, San Francisco, who has written about transitions in care, said that variability in discharge summaries and omission of important data occur not because physicians disagree on what needs inclusion but because hospitalists are busy and may not have time to adequately coordinate care with the primary care practice.

A larger problem than omissions, in Dr. Bodenheimer's experience, is timeliness of the discharge summary. He noted that sometimes primary care physicians are not even informed of their patient's discharge.

Bodenheimer said. At least one study has demonstrated a trend toward a decreased risk of readmission when the discharge summary arrives before the discharge summary outline follow-up visit takes place. If a hour turnaround time is not possible, Dr.

Bodenheimer said he wants a phone call to inform him of his patient's discharge. These include automated red flags. For instance, a hospital can allow hospitalists to discharge a patient only when they enter the summary.

The disadvantage with that safeguard, Dr. But he added that hospitalists should complete the summary on the day of discharge. Another solution to ensuring timely completion and delivery of discharge summaries is for the hospital to audit hospital records However, Dr. In addition to directly sending the summary to the outpatient physician, all of the hospitalists interviewed for this article said their hospitals also give the discharged patient a copy of the discharge summary to hand-deliver to their physician.

Electronic health record systems also likely will speed both completion and transmission of the discharge summary as more hospitals go online. However, independent physicians often do not have the same electronic data systems as hospitals, Dr.

Pham said. When they do, as is the case with many community physicians affiliated with Northwestern Medical Center, they may receive an email that their patient was discharged, Dr. Williams said. Even with technological advances that improve discharge processes, Dr.

Also from ACP, read new content every week from the most highly cited internal medicine journal. Visit Annals. The NQF, in its Safe Practice 11, recommends that a discharge summary include, discharge summary outline, at minimum, the following: reason for hospitalization with specific principal diagnosis, significant findings, procedures performed and discharge summary outline, treatment, and services provided to the patient, discharge summary outline, the patient's condition at discharge, education provided to the patient and family, a comprehensive and reconciled medication list, and a list of acute medical issues, tests, and studies for which confirmed results were unavailable at the time of discharge and that require follow-up.

Don't be late A larger problem than omissions, in Dr. Cover Story. Physician Profile. Success Story.


Creating a better discharge summary | ACP Hospitalist


discharge summary outline


Creating a better discharge summary. The discharge summary is a vital tool for transferring information between the hospitalist and primary care physician, but it isn’t always given the priority it deserves. By Kathleen Louden. T he discharge summary is a vital tool for transferring information between the hospitalist and primary care. This discharge summary consists of 1. The Initial Assessment, 2. Course of Treatment, 3. Clinician's Narrative, and 4. Discharge Status and Instructions _____ _____ 1. INITIAL PSYCHIATRIC ASSESSMENT 3/12/ Complete Evaluation History: Anna is a . 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.