Hospital Discharge Flashcards
S stands for
subjective
ex: how are the patients feeling, improvement or worsening of symptoms related to admission, any new symptoms
O stands for
Objective
what is included in objective?
- PE
- Labs
- imaging
- procedure
from last note
a stands for
assessment
what is included in assessment
Admitting diagnosis
is it the same or does it need to be amended
what does P stand for
plan
what is included in plan
- new lab or imaging orders
- medications to be continued, changed, or D/C
- any changes to previous orders
what does the discharge summary include?
- date of admission
- date of discharge
- admitting diagnosis (or multiple)
- discharge diagnosis (primary or secondary)
- Attending physician and your name
- referring physician
- consults
- procedures performed
- Brief history, PE and lab data
- hospital course
- Discharge exam
- discharge diagnosis
- discharge plan (condition, disposition, meds, instructions, followup)
- time spent creating discharge summary
- name
what types of things should be included in procedures?
surgery, invasive diagnostic procedures
what should be included in history, PE and lab data
- brief overview of h&p, lab test
- summary of pt admission
- how the pt arrive
- significant findings
- reason of admission
- PAST TENSE
what should be included in the hospital course?
things important for the provider seeing the pt afterwards
*chornological order
* evaluation
* treatment
* significant events that occur
* continue until problems resolve
* resolution of problems/ROS
*
past tense
what should be included in the discharge exam
vitals at the time of discharge
physical exam (complete)
what components should be included in the discharge diagnosis?
each diagnosis listed, summary, improvement, and treatment plan
what does PCA stand for?
Pt controlled medication
