How do you write a surgical discharge summary?

How do you write a surgical discharge summary?

6 Components of a Hospital Discharge Summary

1. Reason for hospitalization: description of the patient’s primary presenting condition; and/or.
2. Significant findings:
3. Procedures and treatment provided:
4. Patient’s discharge condition:
5. Patient and family instructions (as appropriate):
6. Attending physician’s signature:

What is discharge from surgery?

When you leave a hospital after treatment, you go through a process called hospital discharge. A hospital will discharge you when you no longer need to receive inpatient care and can go home. Or, a hospital will discharge you to send you to another type of facility. Many hospitals have a discharge planner.

Can a nurse write a discharge summary?

If you are an advanced practice nurse and providing care to a patient, authoring a discharge summary on your own is well within your scope of practice under your state nurse practice act and its rules.

What is safe discharge from hospital?

“This is one of the prices we pay for autonomy.” “Safe discharge” laws preclude hospitals from discharging patients who don’t have a safe plan for continued care after they leave a hospital.

Who is responsible for discharge summary?

Interpretive Guidelines §484.48 – The HHA must inform the attending physician of the availability of a discharge summary. The discharge summary must be sent to the attending physician upon request and must include the patient’s medical and health status at discharge.

How to write a discharge summary?

Discharge Summary Template Date of Admission: Date of Discharge: Attending Physician: (should be the attending on the day of discharge) PCP: (must include the name of the PCP or clinic, “out of town” not acceptable) Admission Diagnosis: This should be the reason for admission (e.g. dehydration, respiratory distress, hypoxia, abdominal pain), not the discharge diagnosis.

What are the requirements for a discharge summary?

– Thirty-four percent of discharge summaries lacked information on the reason for hospitalization. – Sixty-six percent of discharge summaries lacked information on the procedure performed. – Fifty-seven percent of discharge summaries lacked information on a follow-up care plan.

What should be included in a hospital discharge summary?

Your discharge plan should include information about where you will be discharged to, the types of care you need, and who will provide that care. It should be written in simple language and include a complete list of your medications with dosages and usage information. How do you write a discharge summary? Demographics. Clinical details.

Is a discharge summary always required?

Often, the discharge summary is the only form of communication that accompanies the patient to the next setting of care. 1 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. 1, 3, 4, 5