Discharge Summary

  1. Discharge Summary
    • “Discharge summaries are to be done within 36 hours of discharge or prior to transferring a patient to another facility”
    • A discharge summary can replace a progress note for the day
      • Ex. Discharge Mr. Hill at 2pm and complete discharge summary = no need for progress note that day
    • Type: Discharge Summary
    • Note Template: Inpatient Discharge Summary
    • Title: “CAMC IM Discharge Summary”
      1. Dates of Service/Admitting Diagnosis/Primary + Secondary Discharge Diagnosis
        Picture 1
      2. Procedures/Consults
        Picture 2
      3. Studies
        • Use the .jsimaging_report dot phrase
          • Note: ECHOs/Vascular Studies are not added in this dotphrase and must be added manually.
          • Try to delete extraneous information if possible
            • Ex.

              1. CTA w/o Contrast
              2. MM/DD/YYYY 12:00:00
              3. IMPRESSION: Bad study
              4. Electronically Signed by: Reading Physician

      4. Hospital Course
        • Within the hospital course field on your Inpatient Workflow Discharge Platinum or within your inpatient workflow, you can complete the hospital course to auto populate into your discharge summary
          Picture 3
      5. Physical Exam/ Follow-Up Appointments/ Follow-Up Labs/Studies
      6. Discharge Medications/ Pending Labs and Studies/ Condition on Discharge
        Picture 4
      7. Patient Instructions/Discharge Disposition/Physician Orders/Signature
        Picture 5