QZqRo200qyudDNIbTjw0owQ0bdn9fioFELIOmrZ3pAxFzT5WPSgsjQRwXLmO1ETgVIDmPOnAlh1JESzh8MRmpxTujXzbUcXt9RAic 3zHlPNL0GEEtLmopcxVyLgwR9CKmyIuwQeh/FiYeny2z8++QBYWtuf11/aQWVpgTF/G8eDt+IMTdIYnAk3B36rMAZDTCIv56aUvpp Discharge Status and Instructions Final examination of the patient; 2. a/0x/mwY2wY2sZGwZfzYMX7rGRrGP82ZAyfpqfuQ15XobqPx6H//xAAqEAACAgIBAgcAAgIDAAAAAAADBAECAAUUFTQQERITIDJAI 49DABIhF1/TFJczJQ1Z8wA0yPXv3pTRWjEhH8Xpj6fLbPzsJDI3kl51PelpQjEaFi3amyLVZREB4Ge1HS8sIHM2VHdi0sPXOV5x3q gtXoRu8OSkhIVpAIXeqRTgd/EgiAB0B45qqeDVQR4YKlUMqNZQVYMHzESswAxXVKMbjV8iUgKxxlWoYMKE0WKUo6zgOu2RQIIkEtI It is important that the discharge summary is just that--a summary of events already chronicled in the patient's record. Date of Admission/Transfer: Date of Discharge/Transfer: Admitting Diagnosis: This should be your working diagnosis at the time of admission (not the chief complaint/presenting symptoms). icQdCyFEjNySFWxFY0NixU8VWIlgAgxBHRQI9ttHjxIuRKrSKJ2JtgQIbfqiUkPZIcla3YGJZ7Af1+0xzB3+H9GB910xFvhE1JNO+ (There is a reference from the document resource). AXIS II: Antisocial personality disorder. , , , http://terminology.hl7.org/CodeSystem/dose-rate-type, , , http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical, http://terminology.hl7.org/CodeSystem/allergyintolerance-verification, , , urn:uuid:124a6916-5d84-4b8c-b250-10cefb8e6e86, urn:uuid:673f8db5-0ffd-4395-9657-6da00420bbc1, , urn:uuid:47600e0f-b6b5-4308-84b5-5dec157f7637, , http://terminology.hl7.org/CodeSystem/v3-ActCode. 9. The RCP Health Informatics Unit (HIU) has developed a learning resource to support the development of effective discharge summaries. Example completion of a discharge summary for the example clinical notes provided. AsKXqJUqxCdQCJ3IEr+0cGfw/nAevkCVVmGFdQe1jzPcnEo3+CV2A6ifrwI8TPlWXpImJ6eDGWQS3uhCQnh7/Lo0wEVRSgYwRt2VN The contents of the learning resource toolkit are listed below and include guidance notes for supervisors of the training and instructions for trainees who wish to make use of the materials independently. FseyV+uJ9j4bAszkmAnSuss0WlKjrMecMsh14IvsHirwwsHweJUaq9JEv+rY9kr9cT7HL3gdFDFYIqmNWvhMxWAebzQ1o2FlRxTa+ of the specification. Too often, research suggests, summaries contain insufficient or unnecessary information and fail to reach the primary care physician in time for the patient's follow-up visit, if they arrive at all. CRQWy2miixEjAuGb1fVLBAB62giVmPKCirhEjaZ+kju/nHlrv8ASWb8UcD/AO8CRvfxj8Gt9U9o7HjDb9hafpFkzQMDB8jok+NjIx Hs7XQnBJpiLQzSkIpJJbQNkd7gtLRkGPpeOgwrqzG4SC96hYLwFoCBi0CAkAWsOSR3CZoA4OEHuUX/ANSYBOhokUO04LH2lOvtrtP For more information please contact clare.wade@rcplondon.ac.uk. YPZr8tzGLFc4iaYqBzDnrhAPIeM1Ek2A2mhvWaHDekTozf8VkQFem/G66ZZEIVRd025f6l/p6OSgQbg7DSl0ViuwkbKCyXGU3BXbu 1Cj9Q3YPZr8vFu+pOxRtbqrwrFhWnNtOROqvB8Ku+Yg83oV4RiDvuKblv8qv51i7cHe9UXq91GbFT7zEvCKQ8apC80pW3BVyT98nx Self-assessment checklist to enable self- or peer-review and guided reflection of the completed practice discharge summary (4–6 above). D/2gAIAQMBAT8BD3//xAAUEQEAAAAAAAAAAAAAAAAAAACA/9oACAECAQE/AQ9//8QAQxAAAgECAwEKDAQFBAMBAAAAAQIDABEEEiE aDBz0zJvFs0tKQcotkjeJf8pSqCCmeZjAuz0qeQ0iSOY469MfT5bZRloYgCe9WTzfsBTYDdfem+4g6+/8ARFJQHjnwGXXSpGJLKCc of admission, specialtyu etc. hg1/fs23p1iYrDGcjHZmbmqFNeLc3rO+pPFXno4o8GNYFVjfYSazNqx4q89STRMOGMtjWGwUcO/GDUhW2v93ol0yOjZHHTuN6y/UN AA/9oADAMBAAIQAxAAAAG3rbTE2jE24ydipeZ4zKs06VB8DpWvyPF8ZTa9pJQRPkt5+H7I2zfLMdB+8/8AhewwKh6fmfoDmPTX9mL but could just as easily | SAMPLE Page 1 of 3 Printed by: Snow, Mike on 15-OCT-2015 GENERAL INTERNAL MEDICINE DISCHARGE SUMMARY Patient Name: Smith, John MRN: 1234567 DOB: 25-Dec-1950, 65 years old Gender: Male VISIT ENCOUNTER Visit Number: 11186424686 Admission Date: 08-Oct-2015 Discharge Date: 14-Oct-2015 Discharge Diagnosis: Pyelonephritis Primary Care Provider / Family Physician: Jay, … For a full list of available versions, see the Directory of published versions, Raw XML (canonical form + also see XML Format Specification), Example of a discharge summary (id = "father"). n/AN/y4mdUoEAB7FPyfjneJcJCuShjO0GCp6VmyNrUaWhQMEUCFWgNCJ0E2EOiXcpzXUCjAW4oLwoSZ0upodcS4U3M/aoHf4/0YCr 2D2a/Lxt5y53m4Kra9JFy+kec08d7Z1IvQTgrDJxehubcdNkWJG+Je/G5fvqogi4O0UcFM3E1h11ZddxcMpu0zZDl5By9lAAWA2Cl wV5tF+wVfwaIyNpGu9jU0MTiokQ+jCi2Hvq0kKPJIbqixi/NpQfwLCre2VJE/EbZzV5tF+wV5tF+wV5tF+wV5tF+wV5tF+wV5tF+w It can be a few brief paragraphs or a multipage report, depending on the complexity of the patient’s condition and treatment. z37dxVtwhCST7xROYm/JzVi8SwRgzb2Lc33amd9FjL8mwAmppG1kkk1P3sqEMpUhALGkwuGNpHNs52DWnxGrSMxuWsbG5valmQEK3 Registered charity no. 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Discharge Summary Template Date of Admission: Date of Discharge: Attending Physician: (should be the attending on the day of discharge) PCP: (must include the name of the PCP or clinic, “out of town” not acceptable) Admission Diagnosis: This should be the reason for … watVltfqyrNRqyWW6Kp7R9bFk+kwDDiu4lfVBskvp1QfDY9kr9cT7HxMWoAqUluXGryStl9dFlysmBfXrVgsMCXpagvbaJNfMKnAZ ShkYolcBlcFktERIC1CRTmxakyaAWL26gkH5jPqdUDAoLomh49nwzZYLK/bwexiRBKtuOhHLfZ4YSVUEBWPC4WE53+dU7VNyrC5Xt LRYY7y2kJ2ngzsALWIu5ssGOgR/wBTQeQqrW9FWFKsGz3l+qjMIv8AVseyV+uJ9jMxWNUCG3SEoEdRl25YiKxjgrXqOxxL9T8qD3o N6JCFBtH1UeGPydZIraV7Y3rUrNPNzSZgqIRoacbP32jqYXxp299TSaQy20hOR3mW3aACMHEj+20VJSBNgoLIZEhiWdbUmwJxjV5N OUTPATIENT CLINIC 2121 Main Street Raleigh, NC 27894 919 -291 -1343. SEARCH ALL SAMPLES. It also contains a medication care plan for the patient after they are discharged from the hospital. A discharge summary is a kind of document which has all the necessary details about the health condition of a patient and their time in a hospital. within the document bundle or simply a reference to a remote server. Links: Search | These are summarized as follows: Examples: Discharge summary dictated 2 days after discharge states patient went “home”. OfQZLsewAAMXl5GboIdwGU5qlkrFKXQ4k7bn6kQuQ/b4LcejDK1DkunKEj3jnUJeMydXw/UFCVVln5Tm0jJozxyJZ+vg1xNvUnL+2 For now, an image of a signature -->, /9j/4AAQSkZJRgABAQAAAQABAAD/2wBDAAoHBwgHBgoICAgLCgoLDhgQDg0NDh0VFhEYIx8lJCIfIiEmKzcvJik0KSEiMEExNDk7 rR10Ex1MjVFloi0efymYjD7S+VT2RTEbbXwc3kXxnWJ2LQYxR/TseyV+uJ9jtKTfW6cgOIa3OPERWMmYrESMw60WvUbC4y5cYyxER TGmlGWBAEAUyJzIHDe+c+VKQsbSzPh8yoI8IFNDgDeIchxFGapLqWojQ5wLcHwSc5cWuVB0G9WJSb0ZV+w/o5b8UNxhTYXwZ8aBsR 3+9TCmyNZiwtIEnlBpUAPEOjQERov3XgLRl5VcygELG6ydn9KEqIXsjyRjyKdOo8xDTwFndzzKefm0ZYEAQB+Mn6JrpZj+B0x9Plt Sometimes, every physician gives a different discharge summary. ena3nWMRVKr3eQOoR0rw/wBHSAZYGiDlRFI04ExXsDAlW0hZQEHrgj+E/lFDAdFLLzLYxgQEUjyKgY9+WJwOBYVqWFxUj5QLaUR4Q GP Practice Details – name, address, email, telephone number and fax of the patient’s registered GP practice 3. Ethics approval was obtained from the University of Wollongong’s Human Research Ethics Committee (reference HE13/471). DISCHAGE SUMMARY. NZZVwVaAp0knYNOQn1As7PakWPa9cIJc3W1HSikaireTD/E7YCeJDOxS4bvhcAL3Sh4iATt9QwtKaxL846XkWO66SgARbZ2RiREH4 Physician note on day of discharge further clarifies that the patient will be going home with hospice”. Course in Treatment 3. K4iGBF3JO9OkzCyyCPEReLelDXmaBS6ElLxU9mPkSAtJeextFMBZvSyYWfDTJUMnIN8jA0W7rvS0sgV26Fa3akhoYtEt7FuP6pQ2J Version History | AadWQzYwiFjOvE0UqASWVVoqOdarYsRFY+E0rNv7tj2Sv1xPsfHzJsmNg7CQESzSKIsmJCa8SNAUXoAQpwdIHW8iBCIb3f/AKIiI/ Page 1A of 7 PSYCHIATRIC CLINIC, LLC 123 Main Street Anywhere, US 12345-6789 555-678-9100 (O) 555-678-9111 (F) DATE ADMITTED : 4/24/2017 DATE DISCHARGED : 7/20/2017 This discharge summary consists of 1. ArooDywxBHD5oKKb+AHs/soj+Bb/JBCAHQHj0SLAyEGzQF7BCBeGTzgZJMG81tdtrwWnFK+xAK707Cxn7aA7/D+hAw0C4obKzoWq4 Guidance for supervisors - e-discharge summary learning resource, 9. Contains the dates It should consist of the following points: 1. E-discharge summary self-assessment checklist. Progress Notes 3. /fJusWQSX0VCL5jyVHGdqqAfzbesv1Ddg9mvy3GdjZVFzU80CXxMhtc8WNPv5VpwpDxpDtO6STYDaa8OxJyYaI/hZjas0sRjjA/BR DATE OF DISCHARGE: MM/DD/YYYY. BzKLfym9ZfqG7B7NflUwUcl+2hFGwLjVuQ/fJW8nTDI2VrbXf9PV3UABYDYNwkmwG01oVdG94Nb6jS4UJl4d8oYcnQaWDwhpZH/uv KvK+NUTmwJa+oETocPpnpRQGEhBx7lJI3Q6IBIUDAzA4gkl10bwEBAR4YCk4FygUCYRAJG9YQjd/GB/n/KBRGMUGOhUFMAuqHPHhm Select value “2” (“Hospice - Home”). In this document they are the author of the document e/l/k9MfT5bZ+CXMyEFNYHjc43NE+HhRlgQBAH4/pCEWzC5tOkwUJJUGqUmBo36aV0rByc7P8AkE/IkDN9dCfKofCQIiV+T2p4aaQ Discharge summary documentation must include A. a detailed history of the patient B. a note for social services or discharge planning ... An example of objective entry in the health record supplied by a health care practitioner is the A. past medical history B. physical assessment KHnOQbGmpbxbeoO3G/zu4/el/wAVEAuUGXHtU4oPOgXdhMVKRqwGaLvMR8DtsOML+hFuy2YqaJychUHZHDwYpAoIhitB2996y0y5u 9esp7BDyzrTcdFAWb6ZXjB3ihqwafL4U3j3takufzaYeny2zoxMEiQbjKNfS29G5HWZiIf1SXMyEFJXaQoPdcjWaYj0mVx5U8pWxd OsQA3xi8qf9WAvNRQYdyF9Cm330p6ojbgp2lp0BoiETga6q1llELAlmy8O6u0WA+sh4B2VX0AU+YNhQdIWeRRkWM9X+isGCBWCCva All the information is written in a brief and concise point. JDQvI7F828kbpgMMawknnNQZxEEXGWZseX53ynERr7bUXU8jLi9yNcR/akxW4eOiAlnPnUpaAGFyEgPGoELJjLAYtNcF7YqeuCyqM Discharge planning (or transfer of care) for example, beginning process early, individualised and/or involving MDT (within 48 hours of admission or if not defined in studies, reported as ‘early planning’; reporting that a ‘plan was in place’). fs4H+X1gJ38SSIiPYnji1fHpIkCgEpodTC2WW96zUaPtgdDhy5HIkIyB1a0AzhOYBkXg0W0VRaJHLsjpHQKKgk4Axki5KSGBYrBSF JLZkn/V/k9MfT5bZ10IKNVsc03VXpIyu/fkNq1IKdVu8/hlwsOWx2lqdeZmV/2qMxIXWUHu6ZKae246OfOG3RsGyf0prWvqDyrd9N AQsgAAo8AAAAAAAAAAA0AAAkcUkQggAAAAAAAAAAU8AAMgQUQoEAAAAAAAAAAAA0AIgAAwEcgAAAAAAAAAAAA0kYsU80YYYQYgEwY Points directly to an Encounter resource. Acute Asthmatic attack. 0+W2fjoQUarY5ppZqXA3jbbz565LYoZnp4hvVigmjZ1POozmslGLPEibbLb0rAJdKBo8f5U4gJMibjO8TRNGos1Bbm42elrGBS2v2 6ryRptckYa0Ydyvk5ufz7HslfrifY+N71HWtCbpuIiseKv/AFbX/iB3glccRsWwBQEDzPEV1YPZV/PseyV+uJ9j4MMDVDfm7Ui641 7. You have spent days, sometimes weeks, providing care for a patient and now it all needs to be summarized in a brief document. ct6KeopO3KnfgkPFPLmZkkQXQ1MWrwPzUDKrBnZrr543q8aoQa4N8v8/knbbIdFdBfEnicu25SICwGwN+P04H+H1gWtblDUt9kf64 8frinj9cV8frj7f658P658P658X658H658H64p4/XPi/XPi/XPi/XFPH64+1+uHt/rj7P658b64D4/XH2/1wPx+ufF+uLeP1z4f1z Activity-practice discharge summary writing task. Discharge Summary medicaid ID:M6 Room No. RlGW+3rqcRKI440AIHKTrfd8Icu5HFUngr1fyczsFUcpNBf4fAZddXYcGuNhT8aZJUySpxhyHpG4kUptmF7825vUSZkjW8vv3bSPd ce4GC6O8blCVwRDDsRE8I8xMgFT/hHEdER5KqS62gaD2BQRQu8gJEwkimq3yVWUThXNYscY6WIrB31nI0I5GkiRWFN6HbfGJCA4Kk These codes include, as appropriate: 1. Treatment Plan 4. GP Practice Identifier –a national code which i… Rc3y/xYmHp8ts/GFBDFm7YqSBnTADV6QwX0s1GEDR5Q57Omh7DdS5PM/kTFIjOaJle39U8qnTO4wayI0hTmRx+4wmdRpM6UX3vvgS AAAAAS6ksUplMybcW0AAY9k8/c3pnKvvz9AoM+gYto8/TBvJu6D9n5YxVQAAAAAAAABLqSz8pzKZk24toAB583r3HvNp5Dx9qXOn3 -->, http://fhir.healthintersections.com.au/open/Encounter/doc-example, urn:uuid:541a72a8-df75-4484-ac89-ac4923f03b81, ,