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The attending physician or primary physician is responsible for writing and signing discharge summaries and discharge instructions, as they are in charge of the patients care. Nurses assist in the process but do not sign off on these documents. This ensures accurate communication regarding post-discharge care.
What is a discharge summary for therapist?
A therapy discharge summary serves multiple purposes: Whoever reads the therapy discharge summary will know what the client was working on and what progress was made. This helps inform the client on their continuing journey and lets other professionals know what has been covered.
What should be documented in 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.
Who completes the discharge summary?
It is the responsibility of the Nurse Care Coordinator or the RN managing the patients care to coordinate and document the discharge summary.
How do you complete 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.
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The discharge planning process involves an interprofessional team approach. Physicians are responsible for deciding the patient is safe for discharge, creating the discharge plan in conjunction with the rest of the team, and communicating instructions to the discharge nurse or designated discharge personnel.
What is discharge summary discharge?
Thus, the Discharge Summary has pretty clear mandatory elements: what was the patients history, why were they hospitalized, what were the significant events during their stay including procedures and treatments, in what condition did the patient leave the hospital, and what sort of follow-ups are required after
Who is the person responsible for the discharge summary?
Patients leaving the hospital against medical advice; the attending physician should indicate in the discharge summary, but a discharge order need not be written.
Related links
Medicare
This transmittal introduces Chapter 40, Hospital and Hospital Health Care Complex Cost Report,. Form CMS-2552-10, which contains instructions for the completion
An advance written notice of non-coverage helps Medicare Fee-for-Service (FFS) patients choose whether to get items and services Medicare usually covers but
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