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The discharge report must give a summary of everything the patient went through during the hospital admission period \u2013 physical findings, laboratory results, radiographic studies and so on. An AHRQ study points out that the Joint Commission mandates six components to be present in all U.S. hospital discharge summaries.
What is included in a discharge summary?
A discharge summary is a physician-authored synopsis of a patient's hospital stay, from admission to release. It's a communication tool that helps clinicians outside the hospital understand what happened to the patient during hospitalization.
How do you write a discharge summary?
6 Components of a Hospital Discharge Summary Reason for hospitalization: description of the patient's primary presenting condition; and/or. ... Significant findings: ... Procedures and treatment provided: ... Patient's discharge condition: ... Patient and family instructions (as appropriate): ... Attending physician's signature:
Why discharge summary is required?
Often, the discharge summary is the only form of communication that accompanies the patient to the next setting of care. High-quality discharge summaries are generally thought to be essential for promoting patient safety during transitions between care settings, particularly during the initial post-hospital period.
Who is responsible for writing discharge summary?
The MD/DO or other qualified practitioner with admitting privileges in accordance with state law and hospital policy, who admitted the patient is responsible for the patient during the patient's stay in the hospital. This responsibility would include developing and entering the discharge summary.
home health discharge summary example
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The MD/DO or other qualified practitioner with admitting privileges in accordance with state law and hospital policy, who admitted the patient is responsible for the patient during the patient's stay in the hospital. This responsibility would include developing and entering the discharge summary.
What are the components of discharge summary?
From 118 responses, the five highest ranked components of a discharge summary included lists of medications on discharge, diagnoses on discharge, reasons for any changes in medications, and details of follow-up arrangements and treatment in hospital.
Are discharge summaries mandatory?
Even though discharge summaries are not required by all companies, I highly recommended writing them even if you do not take insurance and only accept private pay clients. They are useful for the client and can protect you from legal action. There are all kinds of issues that could lead to legal involvement.
What is a discharge summary?
A discharge summary is a letter written by the doctor caring for you in hospital. It contains important information about your. hospital visit, including: \u2022 why you came into hospital.
What are the components of a discharge plan?
In general, discharge planning is conceptualized as having four phases: (1) patient assessment; (2) development of a discharge plan; (3) provision of service, including patient/family education and service referral; and (4) follow-up/evaluation [12].
Related links
Patient Discharge: Resident EPIC workflow
Discharge summaries are required for billing and need to be completed soon after discharge. Each service has a specific template for the discharge summary.
Documentation of Mandated Discharge Summary ... - NCBI
by AJH Kind · 2008 · Cited by 85 — Hospital discharge summaries serve as the primary documents communicating a patient's care plan to the post-hospital care team., Often, the discharge summary is ...
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