Hospital Discharge Summary Key Components
A discharge summary is a key document prepared by health professionals when discharging the patients from a hospital. It outlines the details of the hospitalization of the patient from admission through discharge. The discharge report has to provide a summary of everything the patient went through in hospital admission period – physical findings, laboratory results, radiographic studies and more. Medical transcription companies ensure accurate documentation of audio/text files of discharge summaries and other reports.
The key components that must be included in the patient’s discharge summary are as follows Reason for hospitalization Chief complaint or the patient’s primary condition History of present illness Key findings or diagnosis Primary diagnoses Procedures and treatments provided Course or events occurring during hospital stay Hospital consults Hospital procedures
Patient’s condition on discharge Health status on discharge Instructions for patient and family (as appropriate) Discharge and admission medications Activity orders Therapy orders Dietary instructions Medical follow-up plans Attending physician’s signature Electronic or physical signature A structured discharge summary is important for medical as well as legal purposes and to promote patient safety.
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