What is a hospital discharge summary?

Introduction. Hospital discharge summaries serve as the primary documents communicating a patient’s care plan to the post-hospital care team. 1, 2. Often, the discharge summary is the only form of communication that accompanies the patient to the next setting of care.

What is included in a discharge summary?

These questions included the 6 elements required by The Joint Commission for all discharge summaries (reason for hospitalization, significant findings, procedures and treatment provided, patient’s discharge condition, patient and family instructions, and attending physician’s signature)[9] as well as the 7 elements ( …

How do I get a hospital discharge summary?

When a healthcare provider creates a discharge summary, it will be sent directly to the intended recipient, as per current practices. When a hospital is connected to the My Health Record system, a copy of the Discharge Summary can also be sent to the patient’s My Health Record.

Why is a discharge summary important?

Physicians and other practitioners need to know details about the care a patient receives during an inpatient hospital stay. Discharge summaries are an invaluable resource that may improve patient outcomes by providing for continuity and coordination of care and a safe transition to other care settings and providers.

How does hospital discharge work?

What is hospital discharge? When you leave a hospital after treatment, you go through a process called hospital discharge. A hospital will discharge you when you no longer need to receive inpatient care and can go home. Or, a hospital will discharge you to send you to another type of facility.

How do I get a hospital discharge letter?

Each hospital has its own discharge policy. You should be able to get a copy from the ward manager or the hospital’s Patient Advice and Liaison Service (PALS).

How do you write a discharge summary?

6 Components of a Hospital Discharge Summary

1. Reason for hospitalization: description of the patient’s primary presenting condition; and/or.
2. Significant findings:
3. Procedures and treatment provided:
4. Patient’s discharge condition:
5. Patient and family instructions (as appropriate):
6. Attending physician’s signature:

Is a discharge summary required?

Even though discharge summaries are not required by all companies, I highly recommended writing them even if you do not take insurance and only accept private pay clients. They are useful for the client and can protect you from legal action.

What is an electronic discharge summary?

Electronic discharge summary (EDS) systems eliminate possible sources of error that may result when scanning or faxing paper-based discharge summaries.

Who writes the discharge summary?

A discharge summary refers to a clinical report prepared by health professionals that outlines the details of the hospitalization of a patient. Lack of discharge details, diagnosis information or patient’s health status in discharge summaries can lead to poor treatment plans.

Can you discharge yourself?

The doctor will discharge you when you are better or you can discharge yourself at any time. If you decide to leave before your doctor thinks you are well enough you will be asked to sign a ‘Discharge Against Medical Advice Form’, you do not have to sign it.

What should be included in a hospital discharge summary?

The discharge summary should include basic information like the period of time that the patient stayed in the hospital, the patient’s condition when they arrived at the hospital. the patient’s condition during the hospital stay, the diagnosis given, the treatment given, the medicines given, and the patient’s condition upon discharge.

Why are hospital discharge summaries very important?

To facilitate hospital recovery audits . In the United States, hospital discharge summaries are very important in making sure that hospitals and healthcare providers receive what they are due in terms of Medicare and Medicaid payments. (Other countries may have another system and name for this service.)

What are the components of a discharge summary?

The Joint Commission mandates that discharge summaries contain certain components: reason for hospitalization, significant findings, procedures and treatment provided, patient’s discharge condition, patient and family instructions, and attending physician’s signature.

What is a nursing discharge summary?

Discharge summaries reflect the reassessment and evaluation of your nursing care. They’re commonly combined with patient discharge instruction forms and provide useful data about additional teaching needs and the patient’s ability to care for herself.