NC DHHS Sample Discharge Summary 2019-2025 free printable template

This document is used to summarize the discharge information and treatment outcomes of a client from a treatment program.

Instructions and Help about discharge summary

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...

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