Academic clinical discharge summary notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, to develop and demonstrate critical thinking and clinical reasoning skills, and to practice identifying acute and chronic problems and formulating a evidence-based plans of care.
Develop an academic clinical discharge summary note based on a hospital patient seen during clinical. The discharge summary note should include the following:
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Reason for admission: Include the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis.
List of all procedures: Include all dates, significant findings, and any anesthetics and contrast used during procedures.
Complete list of consults during hospitalization: Include any providers or services consulted during stay.
Patient\’s condition at discharge: Include a physical exam prior to discharge that documents that patient is stable at discharge and has safe disposition and transportation. What diagnostic criteria confirmed the discharge diagnosis?
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Complete list of discharge medications: Full list with all dosages, frequencies, and quantity of medications prescribed or dispensed.
Pending test results for follow up: Complete list of any pathology, cultures, radiology, or other diagnostic tests still pending, and who is responsible for follow-up on final results.
Complete list of discharge instructions: Full list of directions regarding infection prevention, new medications, and returning to daily activities.
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Complete list of discharge follow-ups: Full list of any therapies, treatments, referrals, consults, and follow-up appointments. What diagnostic criteria were needed after discharge?
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Summary: What questions were raised during the hospital stay? Include all explanations and answers to these questions. What questions were raised that required further exploration? What kind of discharge planning did you need? Characterize your patient interaction activities.
Overall assessment: Identify health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes.
Incorporate three peer-reviewed articles in the assessment or plan.
MODEL ANSWER
Discharge Summary
Discharge Summary
Date
8/6/2021
Patient Name: H.J
MRN: 127452
Sex: Male
Date of Birth: 12/12/1947
Provider: Royal Healthcare Services for the Elderly
Primary Care Provider: Dr. M.J
Admission Date: 03/05/2021
Discharge Date: 07/06/2021
Admitting Diagnosis
C25.9. Patient diagnosed with malignant neoplasm of the pancreas; not well specified
E11.51. Patient is diagnosed with a type 2 diabetes w/diabetes in the peripheral angiopathy as well as w/o gangrene
J44.9 Possibility of chronic obstructive pulmonary disorder
Z93.1. Patient diagnosed with gastronomy status
Z95.820. Possibility of peripheral vascular angioplasty status that is with implants as well as grafts.
Z87.891 Patient gives a personal history of the use of nicotine.
Discharge Diagnosis
I10 controlled for a renovascular hypertension
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N18.6 patient demonstrated a stage renal condition with a peritoneal dialysis done on a predefined date before being discharged.
I70.1 patient shows an atherosclerosis of the renal arterial condition
I25.1 patient has atherosclerotic heart condition specifically of the native coronary heart condition. The patient requires the use of a catheterize at the time of admission
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Procedure for Admission
Consultations: A physician did a whipping surgical procedure to have the head of the pancreas, the duodenum as well as the gall bladder to be removed.
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Course of Treatment:
The patient is a 75-year-old African American male patient who came to the clinical setting after being diagnosed with duodenal mass, neuroendocrine carcinoma that was poorly differentiated in the previous year and later was repaired using a Whipple surgical | PLACE YOUR ORDER NOW AT writtask.com | procedure is often used as a surgical process for treating pancreatic cancer especially when the tumor is stationed at the head of the | PLACE YOUR ORDER NOW AT writtask.com | Whipple procedures where the lower side of the stomach, the head as well as all the duodenum is removed, the modified procedure doesn’t interfere with the stomach, the duodenum as well as the rest of the uncinated process | PLACE YOUR ORDER NOW AT writtask.com |
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