1 / 1

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

astra
Download Presentation

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

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. 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)

More Related