In consultation with clinical staff in the hospital and colleagues at Harry Comay Hospital, a new discharge summary
template was created.
Get copies of investigation reports and discharge summary
for own records as the original papers will be kept by the hospital.
Based on service type, the medical transcription services is classified into History and Physical Report (H&P), Discharge Summary
(DS), Operative Note or Report (OP), Consultation Report (CONSULTS), Others (Pathology Report (PATH) & Radiology Report (x rays or radiographs)) market.
The Discharge Summary
was the poorest source for all elements.
Even this discharge summary
has a lot of information in it that doesn't have to be coded; it has to be extractable for human readability.
The patient was under treatment at a hospital in UP which referred her to Delhi without any medical reports or discharge summary
Until this point, at the time of release, all inmates from the prison system had been given a standard medical discharge summary
, including any and all diagnoses, current medications, allergies, and information about possible postrelease appointments.
Coders are only as accurate as the source they use, most frequently the discharge summary
which is generally completed by the most junior doctors".
At "go live" in 2005, just four note templates (nursing status discharge report, patient discharge instructions, physician discharge summary
, post-operative anesthesia note were available for use.
Clinical care record (problem list, clinical history) 2010 All 17% 2011 All 24% 2010 Most Wired 30% 2011 Most Wired 41% E-prescribing 2010 All 9% 2011 All 18% 2010 Most Wired 18% 2011 Most Wired 34% Laboratory results 2010 All 22% 2011 All 32% 2010 Most Wired 30% 2011 Most Wired 45% Discharge summary
2010 All 16% 2011 All 26% 2010 Most Wired 26% 2011 Most Wired 42% Source: Hospitals & Health Networks' Most Wired Surveys, 2010 and 2011 Note: Table made from bar graph.
In fact, I read his discharge summary
from the hospital in July 2009, which declared him "Not expected to live more than one to two weeks.
For 116 (51%), a preexisting medical condition was described in the discharge summary