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 ?
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.
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.