NC DHHS Sample Discharge Summary 2011-2024 free printable template

Sample Discharge Summary Client Name: Admitting Date: Admitting Diagnosis: Date: Discharge/Termination Date: Discharge/Termination Diagnosis: Treatment Level Recommended: Short Term Long Term Day

How to fill out discharge summary template form

How to fill out discharge summary template:

1. Begin by filling out the patient's demographic information, including their name, date of birth, and contact details.
2. Provide a brief summary of the patient's medical history, mentioning any pre-existing conditions, surgeries, or allergies.
3. Document the reason for hospitalization, including the diagnosis and any relevant tests or procedures performed.
4. Describe the course of treatment given to the patient during their hospital stay, including medications prescribed and any surgeries or interventions conducted.
5. Summarize the patient's progress throughout their stay, mentioning any complications or improvements observed.
6. Outline the discharge plan, including any follow-up appointments, medications to be continued, or lifestyle recommendations.
7. Before finalizing the discharge summary, ensure that all relevant healthcare providers involved in the patient's care have been mentioned and their contributions acknowledged.

Who needs a discharge summary template:

1. Healthcare professionals: A discharge summary is crucial for medical practitioners involved in the patient's care post-hospitalization.
2. Patients: The discharge summary serves as a reference for the patient, helping them understand their medical condition, follow-up care instructions, and medication details.
3. Caregivers or family members: Having access to the discharge summary enables caregivers or family members to assist the patient in post-hospitalization recovery and support decision-making.

Video instructions and help with filling out and completing discharge summary template

Instructions and Help about patient discharge instructions template form

What's up I'm Kenney Babcock and this video is going to cover how to write a discharge summary the first time I cared about writing a discharge summary was about two seconds after my resident asked me to write one I never had any training and after a quick google search it was hard to find good resources to teach me how to write one chances are in the future you'll read a discharge summary written by somebody else knowing the structure will help you find the information you're looking for about your patient the third reason you should care about discharge summaries is that it's an ACME core interests about professional activity that just means that on day one of intern year you're expected to know how to write one this is a checklist of all the things that should be included in a discharge summary I'm not going to read them to you, but I recommend that you print it off for reference or take a screenshot of it and save it on your phone or computer for later we'll briefly talk about a few parts of the discharge summary and then review an example of the brief Hospital course as well as the patient instructions and medications finally we'll go over some common mistakes that everyone makes when writing discharge summaries the brief hospital course always starts with a summary statement related to the principal problem this isn't the same thing as a one-liner it's a statement that has the patient's age their gender the symptoms they presented with as well as their presumed diagnosis and the reason they were admitted to the hospital only active problems are included in a discharge summary, and they should be listed in order of importance as with many things in medicine there are two major styles or formats for the brief hospital course the first and the one that I'll show an example of in this video is the separate bullet point or paragraph style where each active problem has its own paragraph this is in contrast to the story or narrative style the most important part is that each active problem needs to have a brief description of the evaluation treatment outcome complications and follow-up a complication may be any unexpected event adverse reaction or medical error the patient instructions and medications section is to help patients and physicians understand and remember what they need to do after leaving the hospital don't forget to include new medications that were stopped or changed during the patient's stay always remember to include the reason for a medication change now 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 note that this is not the same thing as the chief complaint which could be something like shortness of breath continue with the physical exam from the initial Camp;P don't copy and paste the entire exam select the exam findings that are relevant to the admission diagnosis in this case the general...

For pdfFiller’s FAQs

Who is required to file discharge summary template?

The discharge summary template is typically completed by the physician or other healthcare provider responsible for the patient's care. It is important that all members of the healthcare team contribute to the discharge summary to ensure accuracy and completeness of the care provided.

What is the purpose of discharge summary template?

A discharge summary template is a document that is used by healthcare providers to summarize a patient's stay, treatment, and outcomes. It is used as a way to communicate the patient's condition, treatment, and follow-up care instructions to other healthcare providers. It is also a useful tool for healthcare organizations to track and manage patient care.

When is the deadline to file discharge summary template in 2023?

The deadline to file a discharge summary template in 2023 has not yet been announced. It is important to stay up to date with any changes in the regulations and guidelines affecting the filing of discharge summary templates.

What is discharge summary template?

A discharge summary template is a standardized document used in healthcare settings to provide a comprehensive overview of a patient's medical stay. It is usually prepared by a healthcare professional, such as a doctor or nurse, and contains vital information related to the patient's diagnosis, treatment, and care plan during their hospitalization. The discharge summary typically includes details about the reason for admission, relevant medical history, procedures and tests conducted, medications prescribed, advice or instructions for post-discharge care, any follow-up appointments, and a summary of the patient's condition at the time of discharge. The template allows for consistency and accuracy in the communication of essential information between healthcare providers, ensuring continuity of care for the patient.

How to fill out discharge summary template?

Filling out a discharge summary template involves providing a comprehensive and accurate summary of a patient's hospitalization and condition. Here is a step-by-step guide on how to fill out a discharge summary template: 1. Header: Start by filling out the patient's name, date of discharge, and the healthcare facility's name and address at the top of the template. 2. Introduction: Begin the summary with a brief introduction stating the purpose of the summary and the reason for the patient's hospitalization. 3. Patient Information: Provide essential patient details such as age, gender, contact information, and relevant medical history. 4. Admission Diagnosis: Clearly state the initial diagnosis or reason for the patient's admission to the hospital. Include any relevant information about the presenting symptoms or conditions. 5. Hospital Course: Describe the patient's progress throughout their hospital stay. Include details about any diagnostic tests, procedures, surgeries, treatments, and medications administered. Mention significant changes in the patient's condition and how they were managed. 6. Laboratory and Imaging Results: Summarize important laboratory test results, such as blood work, cultures, or pathology reports. Include any imaging findings, such as X-rays or MRIs, highlighting any significant abnormalities or changes. 7. Specialists and Consultants: Indicate the involvement of any specialists or consultants during the patient's hospitalization. Specify their names, specialties, and the nature of their involvement in the patient's care. 8. Management and Treatment: Describe the treatments provided to the patient, including medications, therapeutic procedures, rehabilitative interventions, or any lifestyle modifications prescribed. Explain the rationale behind each treatment option. 9. Complications and Adverse Events: Document any complications, adverse events, or delays in care that occurred during the hospital course. Describe how they were managed or resolved. 10. Discharge Diagnosis: State the final diagnosis or diagnoses upon discharge. Include any relevant changes or updates to the initial admission diagnosis. 11. Follow-up Plan: Outline the post-discharge care plan, including any recommended medications, therapies, dietary restrictions, or referrals to other healthcare professionals. Provide clear instructions for the patient to follow. 12. Patient Instructions: Write detailed instructions for the patient to follow at home. This may include information on activity restrictions, wound care, medication schedule, signs and symptoms to watch for, and when to seek medical attention. 13. Summary and Prognosis: Briefly summarize the patient's overall condition at discharge, their prognosis, and any expected long-term or ongoing healthcare needs. 14. Signature: Sign and date the discharge summary, and include your name, position, and contact information. Remember, it is crucial to maintain patient confidentiality and ensure that the information filled out in the discharge summary template is accurate, relevant, and understandable to the patient and any future healthcare providers involved in their care.

What information must be reported on discharge summary template?

A discharge summary template typically includes the following information: 1. Patient information: Name, age, gender, contact details, and any relevant identifying factors (e.g., medical record number). 2. Diagnosis: The primary reason for hospitalization or treatment, including the main diagnosis and any co-existing conditions or complications. 3. Treatment details: A description of the treatments provided during the hospital stay, such as medications administered, surgical procedures performed, or other therapeutic interventions. 4. Test results: Significant test findings, including laboratory results, imaging reports, or any other diagnostic tests performed during the hospitalization. 5. Medical history: A summary of the patient's relevant past medical history, including pre-existing conditions, previous surgeries, and any chronic illnesses. 6. Hospital course: A chronological overview of the patient's hospital stay, including significant events, changes in condition, and response to treatments. 7. Follow-up instructions: Recommendations for ongoing care after discharge, including any necessary medications, recommended follow-up appointments, and specific instructions regarding diet, activity, or lifestyle modifications. 8. Discharge medications: A list of medications prescribed at the time of discharge, including the medication names, dosage instructions, and potential side effects. 9. Discharge instructions: Detailed instructions for the patient or their caregiver regarding wound care, pain management, self-monitoring, or any other post-discharge care requirements. 10. Contact information: Contact details for the primary care physician or specialist responsible for the patient's ongoing care, as well as contact information for the hospital or healthcare facility for any questions or concerns. It's important to note that the specific information required may vary depending on the healthcare facility or the specific circumstances of the patient's case.

What is the penalty for the late filing of discharge summary template?

The penalty for late filing of a discharge summary template may vary depending on the specific jurisdiction and regulations in place. In some cases, there may be financial penalties or fines associated with late filing. Additionally, there may be administrative consequences such as delays in reimbursement or non-compliance with regulatory requirements. It is important to consult the relevant laws, regulations, and agreements in your specific jurisdiction to determine the exact penalties for late filing of a discharge summary template.

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