Discharge/Transfer Process 01/22/13so/rev.lm 1 Summary Discharge planning begins at admission. Page 1 Page 2 Detailed list off all continued & new Home meds for provider to Review and sign. !, 3rd edition. Half of them chewed one stick of sugarless gum three times a day for 1 hour each time, starting the morning after surgery and continuing until discharge. You opened the discharge summary when she came Documentation of Medical Records – Opportunities for Charting Establishing and Documenting a Plan of Care: •Written Plan of Care is established by the Interdisciplinary Team for each patient. In essence, discharge summary templates are documents (usually printed) that contain all the health information pertaining to the patient’s stay at a hospital or healthcare facility. Proper Documentation Example #1: 03/21/14 0815 Dr. J Smith notified of change of status r/t abdominal pain, absent bowel sounds. Indicate the rationale (how the service relates to functional goal), type, and complexity of activity. DISCHARGE STATUS AND INSTRUCTI ONS Final Exam, Interval History Anna is stable. MI ruled out. The case manager informs you that Mrs. Jones just got a bed at Goddard House and the ambulance is booked for 1:30 PM. It is a method of organizing health information in an individual’s record. ‐‐‐‐‐‐‐E. DX: Ankle sprain. Amy J.H. Skilled Documentation Examples of Nursing Documentation: Left lateral calf wound healing as evidenced by decrease in size and amount of drainage from last week. Take medications as ordered, follow precautions. Discharge summaries reflect the reassessment and evaluation of your nursing care. Examples are computerized charting that is designed with drop down menus where the speech-language pathologist can select options. Patient Name – full name of the patient (also the patient’s preferred name if relevant) 2. Focus Charting is a systematic approach to documentation.. Focus Charting Parts. Table. Connect with us on Facebook, Twitter, Linkedin, YouTube, Pinterest, and Instagram. Follow RICE therapy. 1. Patient Name ___________________   DOB: ______________   MRN: __________________, ☐ Did Not Reach         ☐ Left Message                         ☐ Unable to leave message, ☐ Reached                    Spoke With ☐ Patient              ☐ Family/Friend/Caregiver  Â, Documented by:  ______________________________, ☐ Reached                    Spoke With ☐ Patient              ☐ Family/Friend/Caregiver Â,   ☐ Unable to Reach Letter sent after third phone call attempt, Discharge Diagnosis: ______________________, ☐  Reviewed diagnosis and current status with patient or family/friend/caregiver, ☐  Required further instruction/education, Condition worsening or patient appears unstable?    ☐  Yes              ☐ No, ☐ Scheduled follow up appointment with PCP, ☐ Scheduled follow up appointment with specialist or other, ☐  Notified provider (Name of provider)Â, ☐ Instructed to go to ER         ☐ Instructed to go to Urgent Care, ☐ Contacted home care nurse/agency (name), ☐ Instructions/Education provided (Describe) ____________________________, ☐ Other (describe) _______________________________, ☐ Medications reviewed with patient/family/caregiver, ☐ New Rx’s filled and picked up?       ☐ N/A (no new Rx’s), New Rx’s: (list each new medication & dose), Patient taking medications as prescribed?   ☐ Yes    ☐ No. For the nutritionist documentation, the To document skilled services, the clinician applies the tips listed below. Vaginal discharge often changes colors, depending on the time of the menstrual cycle. The other 17 patients received standard care without chewing gum. Philadelphia, Pa., Lippincott Williams & Wilkins, 2005. Everything in the discharge […] Appropriateness of housing. After completing your patient's discharge summary form, give one copy to the patient and put another copy in the medical record for future reference. for signature by the provider the RN completing the discharge summary is required to fill out the complete discharge order in the Discharge screen. This will not be included on transfer summaries or off-service notes. Lippincott NursingCenter’s Best Practice Advisor, Lippincott NursingCenter’s Cardiac Insider, Lippincott NursingCenter’s Career Advisor, Lippincott NursingCenter’s Critical Care Insider, Chronic Obstructive Pulmonary Disease (COPD), Extracorporeal Membrane Oxygenation (ECMO), Prone Positioning: Non-Intubated Patient with COVID-19 ARDS, Prone Positioning: Mechanically Ventilated Patients. Symptoms of a Generalized Anxiety Disorder are not reported today. To help with this documentation, many facilities combine discharge summaries and patient instructions in one form. A perfect combination By combining a patient's discharge summary with instructions for care after discharge, you can fulfill two requirements with a single form. Discharge Recommendations: Utilization of Community Resources. When using this documentation method, be sure to give one copy to the patient and keep one for the medical record. 4. Discharge summary is a document that contain a simple summary of the patient’s health information and their time at the hospital or facility. Hospital Discharge Follow-up Documentation-Sample Template This is a sample template for documenting outreach following hospital discharge. On the other hand, outpatient settings may have software to standardize documentation with templates and spaces for information to be inserted. Use this information to inform the development of a template in your electronic medical record. Definition. To comply with The Joint Commission requirements, you must document your assessment of a patient's continuing care needs plus any referrals for care and begin discharge planning early in the patient's stay. Keep leg elevated. This is a sample template for documenting outreach following hospital discharge. Transitions of Care – How to Write a “Good” Discharge Summary By Kimberly Dodd, MD Imagine the scenario… It’s 12:30 P.M. and you have clinic scheduled in 45 minutes. It is recommended that the discharge chart order remain the same as the in-house chart order to eliminate unnecessary time moving sections of the chart around. Use terminology that reflects the clinician's technical knowledge. The primary nurse wasn't too impressed with what I wrote so she added a lot to her own note. Adaptive equipment requested Continue program at home Encouragement of social/leisure participation Reason for Discharge: Completed TR Program Medical Leave Refusal to participate Lack of participation / interest Completed Medical Tx. IDEAL Discharge Planning. Discharge Chart Order: Place the records in discharge chart order. It also contains a medication care plan for the patient after they are discharged from the hospital. ( also the patient’s health information and their time at the hospital or.! 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