- In medicine, a discharge summary is a clinical report that is generated by a health practitioner at the end of a hospital stay or sequence of treatments. In many cases, it is the principal means of communication between the hospital care team and aftercare providers.
What is a discharge summary from a hospital?
A discharge summary is a clinical report created by health professionals that contains the specifics of a patient’s hospitalization and is given to the patient after the patient has been discharged. Poor treatment plans might be caused by a lack of discharge details, diagnostic information, or information on the patient’s health state in discharge summaries.
What information should be in a discharge summary?
A uniformity in the preparation of transition documents, methods, and plans A written transition plan or discharge summary is created, which contains information on the diagnosis, active issues, prescriptions, services required, warning signals, and emergency contact information for the patient and family members. The plan is prepared in the language that the patient understands.
Why is a discharge summary important?
Physicians and other healthcare professionals must be aware of the specifics of the treatment a patient receives while in an inpatient hospital setting. In addition to providing continuity and coordination of care, discharge summaries can also help patients make a safe transition to different care venues and providers, which can enhance their overall results.
Is a discharge summary required?
However, even if your practice does not accept insurance and just accepts cash payments, I strongly advise you to write discharge summaries regardless of your insurance carrier’s policy requirements. They are beneficial to the client and might shield you from legal action. There are a wide range of situations that might result in legal action being taken.
Who is responsible for discharge summary?
Interpretive Guidelines 484.48 – The HHA is responsible for informing the attending physician when a discharge report has been made available. If the attending physician requests it, a discharge statement must be sent to him or her. It must describe the patient’s medical and health status at the time of release.
What is the discharge process?
When you are discharged from a hospital after receiving treatment, you go through a procedure known as hospital discharge. When you no longer require inpatient treatment and are able to return home, a hospital will release you from their care. Alternatively, a hospital may release you in order to transfer you to another sort of institution. A discharge planner is available at many hospitals.