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discharge summary

also see hospital discharge Procedure: - dates of admission & discharge - reason for hospitalization - discharge diagnosis - significant findings from admission workup - history and physical examination - laboratory studies - imaging studies (Radiology) - other tests - procedures - condition at discharge - discharge medications - include discussion on changes to admission medications - follow-up issues - pending studies & laboratory tests - counseling provided to patient & family - follow-up appointments/plans [2] * 1% increase in 30-day readmissions for every 3-day delay in hospital discharge summary [9] - mean time to hospital discharge summary completion is 8 days [9] - 43% of hospital readmissions occur before hospital discharge summary available [9]

Related

discharge planning hospital discharge

General

medical chart documentation

References

  1. Kane RL. Finding the right level of posthospital care: "We didn't realize there was any other option for him". JAMA. 2011 Jan 19;305(3):284-93. PMID: 21245184
  2. Medical Knowledge Self Assessment Program (MKSAP) 16, 17. American College of Physicians, Philadelphia 2012, 2015
  3. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007 Sep;2(5):314-23. PMID: 17935242
  4. Kanaan AO et al. Adverse drug events after hospital discharge in older adults: Types, severity, and involvement of Beers criteria medications. J Am Geriatr Soc 2013 Nov; 61:1894 PMID: 24116689
  5. Dhalla IA et al. Effect of a postdischarge virtual ward on readmission or death for high-risk patients: A randomized clinical trial. JAMA 2014 Oct 1; 312:1305 PMID: 25268437
  6. Goldman LE et al. Support from hospital to home for elders: A randomized trial. Ann Intern Med 2014 Oct 7; 161:472 PMID: 25285540
  7. Makaryus AN, Friedman EA. Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005 Aug;80(8):991-4. PMID: 16092576
  8. Roy CL, Poon EG, Karson AS et al Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19;143(2):121-8. PMID: 16027454
  9. Hoyer EH, Odonkor CA, Bhatia SN et al. Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland. J Hosp Med 2016 Jun; 11:393. PMID: 26913814