discharge summary


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discharge summary

a clinical report prepared by a physician or other health professional at the conclusion of a hospital stay or series of treatments. It outlines the patient's chief complaint, the diagnostic findings, the therapy administered and the patient's response to it, and recommendations on discharge.

discharge summary

 A document prepared by the attending physician of a hospitalized Pt that summarizes the admitting diagnosis, diagnostic procedures performed, therapy received while hospitalized, clinical course during hospitalization, prognosis, and plan of action upon the Pt's discharge with stated time to followup

discharge summary

A document that outlines the details of the hospitalization of a patient.

Patient care

It is prepared when the patient is released from a health care facility and incorporated in her permanent medical records. It should ideally include the explanation for the patient's admission; a record of her complaints, physical findings, laboratory results and radiographic studies while hospitalized; a list of changes in her medications at discharge; and recommendations for follow up care. For optimal patient care it should be transmitted to or reviewed with her outpatient primary care provider.

Synonym: discharge abstract
References in periodicals archive ?
With regard to the timing of the discharge summary, this was found to have significantly improved from the previous audit cycle.
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.
Upon the patient's return to the dialysis facility after a hospitalization, medication lists from the discharge summary are reconciled with the dialysis facility list to confirm there are no duplicate therapies and to address any discrepancies between medications or doses administered during the hospital stay.
With regard to your questions about a nurse rounding on hospital patients and dictating the "physician's admission history and physical" as well as "physician's discharge summary," collecting data (lab results, intake/output, vital sign trends), performing a nursing assessment, and even recording it in a central location (such as a daily progress note) would not require the nurse to engage in "medical diagnosis or prescription of therapeutic or corrective measures.
The latter section requires that hospitals keep a history and physical examination record, an operative report, a consultations record, a discharge summary, and other detailed patient information.
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.
The narratives in the discharge summary from the original patient record were used to determine the relevant clinical concepts of the admission episode.
Tenders are invited for PURCHASE OF PRINTING AND STATIONERY ITEMS : discharge summary letter head (100 sheets/pad) single colour
The discharge summary and nursing notes on the patient were missing.
Coders are only as accurate as the source they use, most frequently the discharge summary which is generally completed by the most junior doctors".
The key form of communication of patient information from hospitals to GPs is the specialist letter and the discharge summary.