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Generic discharge summary*
By James S. Newman, MD, FACP
It's 9 a.m. The social worker is telling you the nursing home needs your patient by 10 a.m…and you haven't yet started the discharge summary.
Not a problem. Use this handy-dandy generic discharge summary to get the job done! What you lose in accuracy, transitions of care, patient safety and satisfaction will be more than compensated with your personal time saved.
Courtesy of Dr. Newman.
Discharge summary on your patient
Admit date: Earlier this week.
Discharge date: Today.
- Asymptomatic pain—resolved
- Abnormal laboratory value
- Incidental radiologic finding
- Iatrogenic vital sign—aberration
- Non-diagnostic endoscopy
- Non-hypoxic hypoxemia
- Idiopathic hospitalization
- Nosocomial sleep disturbance syndrome
The patient arrived in the emergency department, where he was registered. There was an evaluation by the nurse and physician in a relatively timely manner. An extensive number of labs and images were obtained, several of which were markedly abnormal, and some of which were within normal limits. After consideration, intravenous therapy was contemplated and steroids were considered. There was a heated debate about whether the patient should go to the ICU, surgery, neurology, pediatrics, OB-GYN, rehab, or just be discharged. Finally the patient was, of course, admitted to our hospital medicine service.
On arrival, the patient was placed in a room. Vital signs were rechecked. The team arrived and obtained the history and performed a physical exam. More labs and images were ordered, and high-cost therapy was initiated. Admission orders were placed. A diet was ordered, though NPO status was an option for procedures that might or might not be done. Physical therapy and occupational therapy consults were contemplated.
The patient had variations of the measured vital signs and adjustments were made to the regimen. Certain medications were held, and restarted at adjusted dosages.
The family gave additional non-pertinent information. Numerous questions were asked and several actually answered. DVT prophylaxis was on our radar.
The patient looked really sick for a while and we thought about transferring him to the ICU, CCU or surgery service but then he appeared to improve. We noted a window of opportunity, and discharge plans were made for transfer to another location.
Condition at discharge
Past medical history
Multiple previous surgeries
Undefined disease of the heart
Seronegative noninfectious viremia
Non-diagnostic gland biopsy
Family social history
Contributory and significant family history key to the case was identified. Various social habits that may impact health adversely were noted. The patient may have been retired and had possible tobacco exposure, or not.
There were extensive discussions about code status. We reviewed the prognosis and outcomes of inpatient cardiac arrest and the options available. After prolonged debate with the patient and family, a decision was made.
Continue pre-admission medications, except for the ones we discontinued. As well as those we added.
Patient should follow up with a doctor post-hospitalization. The patient will contact doctor and set this up. Patient should also continue the medication regimen as ordered unless side effects occur, which is very likely, in which case maybe he should stop medications if he thinks it's a good idea.
Patient was told that, should there be questions, he should contact someone sooner or later—probably sooner, although we will be out of town.
Patient was also told not to be readmitted within 30 days.
*No vaguely useful, actual patient information was used in preparing this document.
Dr. Newman is a hospitalist at Mayo Clinic in Rochester, Minn., and ACP Hospitalist's editorial advisor and humor columnist.
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ACP Hospitalist Weekly
From the May 22, 2013 edition
- Warfarin better than heparin bridging during cardiac device surgery
- Intensive-dose statins don't confer greater diabetes risk for post-MI elderly than moderate doses
Cartoon Caption Contest
This issue's winning cartoon caption was submitted by Jennifer L. Norris, MD, ACP Member. Thanks to all who voted!
"I had something else in mind when I asked for an outline of the patient's condition."
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