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The document is a physician's discharge summary for a 70-year-old female patient with a history of breast cancer and recent complications including pleural effusion. The patient underwent thoracoscopy with pleurodesis due to recurrent pleural effusion and was started on Megace for nausea. Despite the procedure, her prognosis remains poor due to her debilitated state and lung condition. She is being transferred to an extended-care facility for further recovery.

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Click ‘Get Form’ to open the PHYSICIAN HOSPITAL DISCHARGE SUMMARY in the editor.
Begin by entering the provider's name and patient details at the top of the form. Ensure accuracy in the Provider's Pt ID and sex fields.
In the 'HOSPITAL DISCHARGE DX' section, input relevant diagnosis codes. For example, enter '174.8' for malignant neoplasm of female breast.
Fill out the 'HOSPITAL DISCHARGE PROCEDURES' section by detailing any procedures performed, such as thoracoscopy with chest tube placement.
Provide a comprehensive account in the 'HISTORY OF PRESENT ILLNESS' section, summarizing key medical history and recent developments.
Document findings in the 'HOSPITAL DISCHARGE PHYSICAL FINDINGS' section, noting any significant observations from physical examinations.
Summarize results in the 'HOSPITAL DISCHARGE STUDIES SUMMARY', including any imaging or tests conducted during hospitalization.
Complete the 'HOSPITAL COURSE' section with a narrative of treatment and care provided during hospitalization.
Finally, fill out the 'HOSPITAL DISCHARGE FOLLOWUP' section with instructions for post-discharge care and follow-up appointments.

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Are discharge summaries required?

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.

Why have a discharge summary?

A discharge summary is a collection of information about events during care of a patient by a provider or organisation. The document is produced during a patient's stay in hospital as either an admitted or non-admitted patient, and issued when or after the patient leaves the care of the hospital.

When should a discharge summary be written?

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."

how to write hospital course

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How do I write a medical discharge summary?

These are summarized as follows: Reason for hospitalization: description of the patient's primary presenting condition; and/or. ... Significant findings: Primary diagnoses. Procedures and treatment provided: ... Patient's discharge condition: ... Patient and family instructions (as appropriate): ... Attending physician's signature:

How soon after seeing a patient must a clinician finish medical documentation?

We can probably all agree that \u201cweeks later\u201d is not \u201cas soon as practicable after it is provided.\u201d Many groups suggest that visits are documented the same or next day, and mandate that all are documented within three days.

What is a discharge summary from a hospital?

Hospital discharge summaries serve as the primary documents communicating a patient's care plan to the post-hospital care team. 1, 2. Often, the discharge summary is the only form of. communication that accompanies the patient to the next setting of care.

What is included in 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 start a discharge summary?

2:32 7:38 How to Write a Discharge Summary - YouTube YouTube Start of suggested clip End of suggested clip Now for an example of a good discharge summary. It always starts off with a reason forMoreNow for an example of a good discharge summary. It always starts off with a reason for hospitalization. In this case an acute exacerbation of COPD. This is also the admission diagnosis.

PHYSICIAN HOSPITAL DISCHARGE SUMMARY.doc - wiki siframework 2025

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Are discharge summaries required?

Why have a discharge summary?

When should a discharge summary be written?

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How do I write a medical discharge summary?

How soon after seeing a patient must a clinician finish medical documentation?

What is a discharge summary from a hospital?

What is included in discharge summary?

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example of discharge summary from hospital

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