Discharge Summary Note
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.
ADMITTING DIAGNOSIS: This is a numbered list of all ACUTE diagnosis the patient had whie hospitalized. This is not their past medical hiostory. Please list them in order of importance and severity.
Consultants: Please list all consultants and their field.
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.
HOSPITAL COURSE: Tells the story of the patient from when they were admitted until now, changes over time, lab studies, procedures, results. and what the consultants felt was needed to be changed or adhjusted.
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.
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 ttype 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?
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 in three days give them a script and write it in here
Follow up appointments: Follow up with PCP in 1 week, Cardiology in 2 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? Be specific.
Remember this is how the primary care physician that takes care of these patients 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.
Progress (SOAP) Note
Cardiology Progress Note and Consult
Learn how to do an H&P correctly!
Look like a superstar physician!
Don't make rookie mistakes!
Outshine your cohorts!
Be able to bill better!
Make a case for a higher level of care!
The money is in the assessment and plan!