History and Physical Advice Tips Secrets

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Discharge Summary

It seems like no one really knows how to do these. These are usually dictated or typed into the medical record. It's to let people know what happened on that hospitalization and how the patients was treated.

Admit Date:

Discharge Date:

ADMITTING DIAGNOSIS: This is a numbered list of all ACUTE diagnosis the patient had while hospitalized. This is not their past medical hiostory. Please list them in order of importance and severity and note whether or not they were resolved, resolving, or chronic.

Consultants: Please list all consultants and their field. Like Dr. Smith- Cardiology. Dr. Jones-Neuro.

Procedures: Please list all major procedures the patient may have had during their stay. You don't have to list minor things like a urinalysis, we are talking CT scans, stress tests, etc.

Hisory of Present Illness: How did they present to the hospital. This doesn't have to be long.

Hospital Course: Tells the story of the patient from when they were admitted until they were discharged. Why they came in, what was done, what we found, who treated them, changes over time, lab studies, procedures, results, and what the consultants felt was needed to be changed or adjusted. Should be the complete story of the patient's stay at the hospital. The primary care physician that treats the patient in the outpatient setting needs to know what happened and why. Should be concise, yet contain enough detail to be complete.

Consultant Recommendations: Include specifics or changes the consultants have made. This should be a different paragraph for Cardiology, Neurology, and each consultant.

Vitals on Dicharge: Their last set of vitals with a date and time.

DISCHARGE CONDITION: good, stable, fair, guarded, critical, etc. For discharge it should always be "STABLE".

Medications: Their final medication list and dosages. Do not say "see medication reconciliation sheet". If you want to do that, please then list in here which medications were discontinued, added or dosages that were changed. Such as, "Please see the medication reconcilation list. Notable changes include his lasix dose being changed to 40mg BID and ..... "

Diet: What type of diet would you like them to be on? Low Sodium? ADA 1200 calorie diet?

Activity: Can they resume full activity? Or do you want them to avoid lifting heavy objects? Can they drive?

INSTRUCTIONS: Daily weights, dressing and/or cast care, symptoms to warrant further treatment, or when to return to hospital or call doctor, etc.

Follow up tests: If you want a BMP or INR in three days give them a script and write it in here. Their doctor needs to know what to follow up on.

Follow up appointments: Follow up with PCP in 1 week, Cardiology in 2-4 weeks. List the names and numbers of the physicians you want them to follow up with.

Discharge to: Home? Or back to skilled nursing facility? Or to assisted living center? Rehab? Do they need Home Health? Has it been arranged? Be specific.

 

Remember this is how the primary care physician that takes care of these patients outside of the hospital is supposed to know what you did to them while they were hospitalized and what they need to follow up on and how their treatment and medications were changed.

 

 

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Medical Notes:
Admit/Transfer Orders
Progress (SOAP) Note
Discharge Summary
Procedure Note
Discharge Summary
Off-Service Note
Pre-Operative Notes
Operative Note
Post-Operative Note
Death Note
Post-Partum Note
Delivery Note
Cardiology Progress Note and Consult

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