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Click ‘Get Form’ to open the SNF Discharge Summary Template in the editor.
Begin by filling out Section I. Enter the member’s name and Tufts Health Plan Medicare Preferred member ID, along with the Case Manager’s name, phone number, and fax number. Don’t forget to include the member’s PCP name and their Medical Group/IPA number.
In Section II, indicate the type of service from which the member is being discharged by placing an X in the appropriate checkbox (SNF, HHA, or CORF). Record the planned discharge date and the date when the Notice of Medicare Non-Coverage was issued.
Proceed to Section III. Ensure all elements are documented in the member’s record supporting the discharge decision based on medical necessity.
In Section IV, provide detailed information about the member's admission date, prior level of function, evaluation details, treatment plans, therapy goals for discharge, current status related to admission reasons, next level of care, and follow-up care.
Finally, complete Section V by printing your name and providing your signature along with your contact number.
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Conclusion: The key components to include in a discharge summary are the discharge diagnosis, treatment received, results of investigations and the follow up required.
What should be documented in a discharge summary?
As with your clients progress notes, your discharge summary should include certain information that sums up your work together, such as: Client information. Diagnosis both their initial diagnosis and their diagnosis at the time of discharge. Current symptoms.
What is a discharge summary from SNF?
A discharge summary must include an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another.
How to create a discharge summary?
A Good Discharge summary will contain. . . Encounter Location/Organzation. Hospital name and service(s) accessed by patient. Diagnosis. Course While In Hospital. Concise description of patients initial presentation. Treatment provided and results of procedures. Discharge Plan. Categorized listing of medications (e.g. home vs.
What must all discharge summaries include?
The Joint Commission has identified six categories of information to include in discharge summaries: reason for hospitalization, significant findings, procedures and treatments provided, patients condition at discharge, patient and family instructions, and attending physician signature.
The MD/DO or other qualified practitioner with admitting privileges in ance with state law and hospital policy, who admitted the patient is responsible for the patient during the patients stay in the hospital. This responsibility would include developing and entering the discharge summary.
What are the documentation requirements for discharge summary?
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 progress note sample
Discharge Summary Template Date of Admission
Brief Hospital Course: This should be a brief, problem-based summary of the admission. Include all pertinent lab values and radiology studies here. If the
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