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Hospital discharge summary sample

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The document is a discharge summary for a client, detailing their treatment program completion, diagnosis upon admission and discharge, recommended treatment level, and nature of discharge. It includes sections for client strengths, presenting concerns, ASAM primary issues, treatment outcomes, discharge plan, referrals, and signatures from both the client and therapist.

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2011	4 Satisfied (50 Votes)

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What is a digital discharge summary?

Electronic discharge summaries will be sent electronically and contain information about a patients episode of care, including their diagnosis and medication while in hospital, to provide the practitioner with the information required to determine the patients ongoing care needs.

How do I get a discharge summary?

You should be able to get a copy from the ward manager or the hospitals Patient Advice and Liaison Service (PALS). Once youre admitted to hospital, your treatment plan, including details for discharge or transfer, will be developed and discussed with you.

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 should a discharge summary include?

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 the standard discharge summary?

The National Standard for Patient Discharge Summary Information consists of the seven groups of headings: Patient details, Primary care healthcare professional details, Admission and discharge information, Clinical information, Medication information, Follow up and future management, and Person completing discharge

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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.

What should be in a discharge summary?

The discharge report must give a summary of everything the patient went through during the hospital admission period physical findings, laboratory results, radiographic studies and so on.

What elements should be part of the discharge summary form?

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.

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What is a digital discharge summary?

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What should a discharge summary include?

What is the standard discharge summary?

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What must all discharge summaries include?

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