Finally, our finding of lack of relevant detail in the Discharge Summary
should alert all Health Information Managers and Clinical Coders to abstract comprehensively from all sources including the entire medical record.
Both JACHO and hospitals generally require that the discharge summary
include a complete description of the patient's care and treatment, a summary of any laboratory and X-ray findings, a description of the patient's diagnosis, and a prognosis.
The operation was successful, but in the diagnosis section of her discharge summary
, along with "adenocarcinoma of the right lower lobe,' and "basal cell cancer skin of face,' a resident, reading from another doctor's notes, added "paranoid schizophrenic.
SHM and QuantiaMD plan to engage thousands more physicians by the end of this year, giving them an improved ability to identify high-risk patients, the tools to enhance discharge summary
communication and ways to better prepare patients, families and caregivers for post-discharge care.
CirrusHealth's first app offers patients a virtual-office-visit (VOV) and video discharge summary
(VDS) focused on providing highly personalized multimedia education content to support patients from one level of care to another.
According to a new market report published by Transparency Market Research " Medical Transcription Services Market (History and Physical Report, Discharge Summary
, Operative Note or Report, Consultation Report and Others & MT Outsourcing and Offshoring) - Global Industry Analysis, Size, Sha re, Growth, Trends and Forecast, 2013 - 2019 " , the global medical transcription services market was valued at USD 41.
The key form of communication of patient information from hospitals to GPs is the specialist letter and the discharge summary
The rest did not have a cause documented in the discharge summary
, said Dr.
We'll push a discharge plan and a discharge summary
out to the primary care physician.
Unfortunately, neither the family nor the attending physician is notified; indeed, the attending dictates "normal CT scan" in the discharge summary
The global medical transcription services market on the basis of service types is categorized into patient history, discharge summary
, consultation records, operative records and other diagnostic reports.
However, there is no unanimous definition of discharge summary
quality in the literature, nor how to achieve it.