Creating a better discharge summary | ACP Hospitalist


discharge summary outline

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). 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. 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.

FREE 7+ Sample Discharge Summary Templates in PDF | Word

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 discharge summary outline 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 hospitalists— including Dr. Yadav at Baystate—are helping their institutions 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, discharge summary outline.

The Joint Commission mandates that discharge summaries contain certain components: reason for hospitalization, significant findings, procedures and treatment provided, patient's discharge condition, 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, medications indicating new, changed, and discontinuedfollow- up plans and appointments, outstanding issues for followup, discharge summary outline, and results of any tests or lab work pending at time of discharge, 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.

The NQF, in its Safe Practice 11, recommends that a discharge summary include, at minimum, the following:. Unfortunately, there is no uniform definition of significant findings. Although some might interpret it to mean discharge summary outline abnormal results, Dr. Yadav does not recommend always limiting the summary to abnormal findings. For instance, not to discharge summary outline that a mass was benign could lead to repeated testing.

Be specific about imaging and other tests, Dr. Yadav suggested. Thomas Bodenheimer, FACP, an internist affiliated with the University of California, discharge summary outline, 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 discharge summary outline 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 outpatient 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 discharge summary outline 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, discharge summary outline. When they do, as is the case with many community physicians affiliated with Northwestern Medical Center, discharge summary outline, 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 care, treatment, and services provided to the patient, 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.


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


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. 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. 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 .