MD Attachment LL - Discharge Summary 10-11: Fill out & sign online

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Click ‘Get Form’ to open the MD Attachment LL - Discharge Summary 10-11 in the editor.
Begin by entering the inmate's name, DOC/SID number, and date of birth in the designated fields. This information is crucial for identification.
Fill in the admission date and date of discharge to provide a timeline of the inmate's stay.
Complete the 'Presenting Problem' and 'Reason for Discharge' sections to summarize the inmate's situation upon leaving.
Utilize EPHR to document the 'Diagnostic Impression at Discharge,' filling out each axis (I through V) as applicable.
Indicate the prognosis at discharge by selecting from options such as Good, Fair, Guarded, or Poor.
List current medications using EPHR and detail treatment progress or behavioral concerns in the provided section.
Finally, complete recommendations for aftercare and ensure that all necessary signatures are obtained before saving your document.

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What is a simple discharge summary?

The Joint Commission has identified a standardized, written discharge summary completed within 30 days of hospital discharge as a key transition of care element to improve patient outcomes.

How do you write a good 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.

How to complete a discharge summary?

Essential information to include in a discharge summary Client information. Diagnosis both their initial diagnosis and their diagnosis at the time of discharge. Current symptoms. Discharge date. Services provided. Treatment summary. Progress toward goals. Reason for discharge.

What are the 5 Ds of discharge?

This formal document gives a detailed overview of the care received, client progress, and recommendations for follow-up care. Unlike other clinical notes, a discharge summary marks the end of care when a client finishes therapy, stops treatment, or moves to another provider [1].