The discharge summary should facilitate the safe transition of care from the hospital setting back into the community, delivering information that is both relevant and accurate to aid continuing care.
A formal discharge summary/note is often required for any patient who was admitted to inpatient status for longer than 24 hours. Discharge summaries serve as the primary documents communicating a patient’s care plan to the post-hospital care team.
High-quality discharge summaries are generally thought to be essential for promoting patient safety during transitions between care settings, particularly during the initial post-hospital period.
This discharge summary assignment must be submitted in a Word document with a title page and references as per APA 7th edition guidelines. Support your diagnostic, treatment, or follow-up rationales using appropriate evidence from outside sources with appropriate in-text citations.
Assignment Requirements:
Before finalizing your work, you should:
Read the assignment details carefully.
Review the Grading Rubric (under Course Resources) to ensure you have included all grading requirements.
Utilize the Discharge Summary template if needed.
Check spelling and grammar (using a word processing tool) to minimize errors.
Your assignment should:
Follow the conventions of standard English (i.e., correct grammar and punctuation).
Be well ordered, logical, and unified, as well as original and insightful.
Display superior content, organization, style, and mechanics.
Use APA 7th edition formatting for all citations and reference pages.
Discharge Summary
Select a patient that you examined during the last seven weeks of your clinical experiences.
With this patient in mind, address the following to complete a discharge summary:
Date of Admission:
Date of Discharge:
Admitting Diagnosis:
This should be your working diagnosis at the time of admission.
Discharge Diagnosis:
Make sure this is a diagnosis and not a symptom or sign.
Secondary Diagnoses:
Include all active medical problems.
Procedures
List all procedures with the date of occurrence and key findings when applicable.
Consultations
List all consultations obtained while inpatient.
History of Present Illness (HPI):
This is a brief synopsis of the initial presentation typically found on H&P.
Hospital Course
Summarized details of daily progression or worsening course while hospitalized; include floor transfers, ICU transfers, etc.
Discharge Physical Examination:
A physical examination that was completed on the day of discharge.
Condition / Disposition
Make a brief statement about the patient’s overall condition at discharge (i.e., “stable,” “fair,” “declining”)
This is where the patient is going after discharge from the hospital (i.e., “home with home health,” “daughter’s house,” “rehab facility,” “hospice house”)
Hospital Diagnostics:
Include all pertinent radiology tests and diagnostic procedures with a brief description of findings.
Discharge Medications:
List all medications that the patient will be taking at home (even if previously prescribed), including dosage, route, frequency, and date of the last dose, if applicable.
Pending Studies
List all studies that are pending a result so that the primary care provider or any other outpatient providers can follow up appropriately.
Recommendations
Include any recommendations for outpatient care, consultations, or studies you recommend the primary care provider consider.
Follow Up Instructions / Discharge Education:
Name of provider, specialty, and appointment location with time and date of appointment, if known.
If the patient is to schedule the appointment, then make sure you include the timeframe by which the patient should schedule the appointment. (i.e., “Patient to arrange an appointment time to be seen within two weeks.”).
Provide appropriate education for the patient, based on their reason for admission or other identified aspects affecting their overall care (i.e., social considerations, lack of medical).
