Hospital Care & Transitions
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STRONG DISCHARGE SUMMARIES ARE: 1. Timely Dictated day of discharge (or within 48 hours) PowerPoint PPT Presentation


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Hospital Care & Transitions. 1. Preliminary Information (Spell all names) a. Patient spelling, MRN, PATCOM b. Dates of Admission/Discharge c. Attending Physician, Service (e.g. ‘Gen Med Team 3’) d. Person Dictating

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STRONG DISCHARGE SUMMARIES ARE: 1. Timely Dictated day of discharge (or within 48 hours)

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Strong discharge summaries are 1 timely dictated day of discharge or within 48 hours

Hospital Care & Transitions

1. Preliminary Information (Spell all names)

a. Patient spelling, MRN, PATCOM

b. Dates of Admission/Discharge

c. Attending Physician, Service (e.g. ‘Gen Med Team 3’)

d. Person Dictating

e. Referring/Primary Care Provider (Include contact information)

  • STRONG DISCHARGE SUMMARIES ARE:

  • 1. Timely

    • Dictated day of discharge (or within 48 hours)

    • Sent to the correct provider(s)

  • 2. Clear, Concise, Complete

  • 3. Forward-looking

    • Medications Reconciled

    • Pending Tests Listed

    • Specific Follow-up Plans Noted

  • COMMON DISCHARGE SUMMARY DEFICIENCIES:

  • Only 12-34% of summaries available at first follow up. (When summary present at first follow up, trends toward decreased hospital readmissions)

  • Many summaries leave out important information

    • 14% omit hospital course

    • 17% omit responsible inpatient provider

    • 21% omit discharge medications

    • 38% omit key test results

    • 65% omit pending tests at discharge

    • 91% omit patient counseling/instructions

  • 2. Admission Information

    • a. Chief Complaint on admission

    • b. HPI (brief, including presenting symptoms and admitting impressions/diagnoses)

    • c. Pertinent PMH/PSH/SHx/FHx

    • d. Allergies/Reactions

    • e. Admission Medications (unless changes noted in discharge med list)

    • f. Admission Physical Exam (pertinent findings only)

    • g. Diagnostic tests (pertinent test results only, not a complete list; recitekey findings rather than entire reports)

    • h. Procedures (list major/invasive procedures)

    • i. Consultations (list services, details to go in the Hosp Course section)

3. Hospital Course

a. (Problem based, formatted in separate concise paragraphs)

  • 4. Discharge Information

    • a. Discharge Diagnoses (primary and secondary)

    • b. Cancer Staging (if applicable)

    • c. Discharge Medications (note medications deleted, changed, or added in relation to the admission medication list)

    • d. Pending laboratory/radiology/pathology tests and/or required follow up tests

    • e. Disposition (to home or another facility noting aftercare services such as PT, OT, or infusion therapy)

    • f. Condition upon discharge (level of consciousness, orientation, limitations in ambulation or ADLs, where applicable)

    • g. Patient Instructions

    • - Activity

    • - Diet

    • - Other specific patient instructions (parameters for calling MD, wound care, etc.)

    • h. Code status at the time of discharge

    • I. Follow up appointments (ideal if specific provider, date, time)


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