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The discharge summary is a narrative document for communicating clinical information about what happened to the patient in the hospital. Its extremely important for telling primary care doctors and other outpatient providers which follow-ups are needed for the patient.
Multiple experts have recommended that detailed information concerning the patients discharge condition be included in all hospital discharge summaries. Nevertheless, no evidence has been published to document the actual impact an omission of this nature has on patient health and safety outcomes.
Hospital discharge summaries serve as the primary documents communicating a patients care plan to the post-hospital care team. Often, the discharge summary is the only form of communication that accompanies the patient to the next setting of care.
Conclusion: The key components to include in a discharge summary are the discharge diagnosis, treatment received, results of investigations and the follow up required.
For example, in the course of an acute exacerbation of an illness, a patient might receive care from a PCP or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility.
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The Discharge Summary/Transition Plan is designed as a two-page form, encapsulating the course of treatment, outcomes, and reasons for transition or discharge. This plan should be initiated as early in the treatment as possible to ensure steps are taken to provide continuity of care.
The Discharge/Transfer Summary is intended to accompany the resident when discharged, transferred or referred to another care setting. It can be sent with the resident for hospital admissions, ER visits, and other health-related appointments.
Conclusion: The key components to include in a discharge summary are the discharge diagnosis, treatment received, results of investigations and the follow up required.