How do you write a good discharge summary?

6 Components of a Hospital Discharge Summary

  1. Reason for hospitalization: description of the patient’s primary presenting condition; and/or.
  2. Significant findings:
  3. Procedures and treatment provided:
  4. Patient’s discharge condition:
  5. Patient and family instructions (as appropriate):
  6. Attending physician’s signature:

What do discharge summaries include?

A discharge summary refers to a clinical report prepared by health professionals that outlines the details of the hospitalization of a patient. Lack of discharge details, diagnosis information or patient’s health status in discharge summaries can lead to poor treatment plans.

What information is included in the Nurses discharge note?

A written transition plan or discharge summary is completed and includes diagnosis, active issues, medications, services needed, warning signs, and emergency contact information. The plan is written in the patient’s language.

When Is discharge summary written?

A discharge summary is a collection of information about events during care of a patient by a provider or organisation. The document is produced during a patient’s stay in hospital as either an admitted or non-admitted patient, and issued when or after the patient leaves the care of the hospital.

Who is responsible for discharge summary?

Interpretive Guidelines ยง484.48 – The HHA must inform the attending physician of the availability of a discharge summary. The discharge summary must be sent to the attending physician upon request and must include the patient’s medical and health status at discharge.

How do I write a discharge plan?

When creating a discharge plan, be sure to include the following:

  1. Client education regarding the patient, their problems and needs, and description of what to do, how to do it, and what not to do.
  2. History of the hospitalization and an explanation of test data and in-hospital procedures.

Who creates discharge summary?

A discharge summary is a clinical report prepared by a health professional at the conclusion of a hospital stay or series of treatments. It is often the primary mode of communication between the hospital care team and aftercare providers.