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The Joint Commission (TJC) mandates that a discharge summary be produced for every patient by the hospital provider within 30 days of discharge,4 and include (1) reason for hospitalization; (2) procedures performed; (3) care, treatment, and services provided; (4) discharge condition; (5) information provided to the
discharge plan must include a living location, services, care, and medications, if needed.
The purpose of the discharge summary is to provide a concise and comprehensive summary of the patients hospital stay to their primary care provider and other healthcare professionals involved in their ongoing care.
A printable Discharge Summary template can make it easier for you to write a Discharge Summary: Step 1: Patient identification. Step 2: Input information. Step 3: Reason for admission. Step 4: Procedures performed. Step 5: Medications prescribed. Step 6: Patients condition at discharge. Step 7: Follow-up care instructions.
The discharge summary must outline the complete list of recommended actions that were provided to the patient and/or carer. This informs primary care providers of follow-up care information that the patient and/or carer was provided.
It is the responsibility of the Nurse Care Coordinator or the RN managing the patients care to coordinate and document the discharge summary.
A written transition plan or discharge summary is completed and includes diagnosis, active issues, medications, services needed, warning signs, and emergency contact information. The plan is written in the patients language.
Discharge summaries can include: the name of the hospital or facility you were discharged from. pathology tests. problems/diagnoses. clinical overview. current medications on discharge. any medications you are no longer taking. allergies and adverse reactions. discharge diagnosis.