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.
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