HTML Preview Clinical Discharge Summary page number 1.
Talk Ten (ICD 10) Tuesday Tips….Got a Minute:
Specificity: noun spec·i·fic·i·ty \ˌspe-sə-ˈfi-sə-tē\
the quality or condition of being free from ambiguity
Discharge Summary Template…Capture it all!
ADMITTING DIAGNOSIS (Reason for hospitalization):
DISCHARGE DIAGNOSIS (Significant findings: all conditions resolved/all
possible and probable diagnoses stated earlier in record/Rule it in/Rule it out
or Resolve it!):
HOSPITAL COURSE (Procedures performed and findings/Surgical
findings/Test results (include any pending or sent out labs not resulted yet)/
Treatment rendered, Description of initial diagnostic evaluation):
REFERRING PHYSICIANS/CONSULTS:
DISCHARGE CONDITION/DISPOSITION: Patient sent (Home/ECC/LTC) ______
in (Good/ Fair/Guarded/Poor)_____________ condition.
EDUCATION:
o FOLLOW-UP:
o DIET:
o MEDICATIONS (New discharge meds; Changes; Discontinued meds):
o DISCHARGE INSTRUCTIONS (For patient and family):
Time Spent: (# minutes ≤ 30 or > 31 min)
Cc: PCP and Consulting Physician(s)
Medical Staff – 5.24.2016