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

 

discharge summary outline

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 . Additionally, note that a discharge summary template is different from a medical report template. Things to include in discharge summary templates. In some countries, all healthcare facilities are required to fill out a standardized discharge summary template for all their patients. 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.


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


Posted by Saleem Kamalodeen Documentation. Discharging patients from a hospital is a complex task. 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. Delays in the completion of the discharge summary are associated with higher rates of readmission, 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 in each discharge summary.

This section should be completed with the details of the General Practitioner with whom the patient is registered:. 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 discharge summary outline 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 discharge summary outline or procedures that the patient underwent:. Include details of the current plan 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:. Discharge summary outline section should outline any allergies or adverse reactions that the patient experienced, discharge summary outline.

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 describes the care of the patient discharge summary outline 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, discharge summary outline.

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We use Google Adsense, which serves personalised advertisements to users based on their browsing activity. The revenue we generate from these adverts discharge summary outline us to keep the website free. Table of Contents. Clinical examination revealed reduced breath sounds and discharge summary outline to percussion in both lung bases.

There was also a significant degree of lower limb oedema extending up to the mid-thigh bilaterally, discharge summary outline. 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, discharge summary outline.

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, discharge summary outline, 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 asked your GP to take some blood 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, discharge summary outline. Transport arrangements e. References 1. Available from: [LINK] 2, discharge summary outline. About The Author. Related Posts. Chiari Malformations NeurologicalNeurologyNeurosurgery. This site uses cookies to provide support and relevant advertisements.

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FREE 7+ Sample Discharge Summary Templates in PDF | Word

 

discharge summary outline

 

Additionally, note that a discharge summary template is different from a medical report template. Things to include in discharge summary templates. In some countries, all healthcare facilities are required to fill out a standardized discharge summary template for all their patients. 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. 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.