The availability of a discharge summary
, with adequately recorded information, has demonstrable direct benefit for the patient.
The doctor writing the discharge summary
will have instant access to all this information, meaning the summary can be produced in minutes.
The patient discharge summary
has all the details about the patient such as prescription, follow-up details, patient education and discharge diagnosis.
A printed discharge summary
and an electronic record for each discharge are created.
Respondents were asked whether or not the practice had the following: (1) a formal care transitions program, and then asked whether the following CTM processes were in place; (2) physician notification by hospital within 2 hours after admitting patient to hospital; (3) physician notification by hospital within 2 hours after admitting patient to emergency department; (4) physician receipt of patient discharge summary
within 48 hours from hospital; (5) physician receipt of patient discharge summary
within 48 hours from emergency department; (6) patient contacted within 48 hours of hospital discharge (support services and schedule follow-up); (7) patient contacted within 48 hours of discharge for medication understanding/reconciliation.
For instance, FHIR creates a straightforward approach to assemble a discharge summary
(document) with data collected from a clinician (API) and a laboratory (message)-assisted by a context-aware application that assembles the document.
Phase III will include qualitative analysis of each callback to ensure all components of the call were addressed and all eight points were documented properly within the discharge summary
. Additionally, a tool will be developed to consistently analyze readmission rates to determine which readmissions were preventable and trend data on primary diagnoses, admitting service, and provider/provider-type to analyze if the callback program aided in decreasing 30-day readmissions.
The medical records of stroke patients receiving treatment including demographic data, age, gender and hospital record numbers, data regarding anti-cerebral edema drugs prescribed, co-prescribed drugs, and discharge summary
were collected from their records.
The completeness of medical records was assessed in terms of physician note, physician order sheet, nursing care plan, medication administration sheet, and discharge summary
. Accordingly, the result showed that physician note format was attached for 111 (100%) and completed for 103 (92.8%), physician order sheet was attached for 111 (100%) and completed for 107 (96.4%), nursing care plan was attached for 109 (98.2%) and completed for 85 (76.6%), medication administration format was attached for 103 (92.8%) and completed for 78 (70.3%), and at last discharge summary
was attached for 107 (96.4%) and completed for 93 (83.8%) (Figure 1).
It is noteworthy that HISTORY OF PRESENT ILLNESS and PAST MEDICAL HISTORY ranked among the top 10 sections in Table 3, suggesting that the history sections that are generally included in most clinical notes (not just discharge summary
) can host abundant exposome information.
Almost every attending is attentive enough to send me a discharge summary
. These, however, are EHR-generated.
A discharge summary
is essentially an assessment of the patient's performance in treatment: which treatment objectives were met, which ones were deferred, which ones need more work, and have any new issues come up in treatment?