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Elements of the Discharge Summary

Introduction

Last Review Date: 01/04/2013
SME:
Director of Social Services

The responsible resident physician documents the Discharge Summary at the time of the patient's discharge.

Discharge Summary due

Documentation is due on the day of a planned discharge, and within 24 hours following an unplanned discharge.

Elements

The following is a summary of the elements of the Discharge Summary document that the responsible resident physician must write at the time of discharge:

Patient Name, Medical Record Number, Date of Birth, Age, Admission Date, Date of Discharge

Reason for Hospitalization

Evaluations

Clinical Findings

Condition at Discharge

Discharge Diagnosis

Axis I primary, and secondary (if present)

Axis II

Axis III

Axis IV

Axis V , Admission and Discharge GAF

Discharge and Aftercare Plan

Discharge Summary Documented By

Discharge Physician Signature

Reason for Hospitalization

The reason for hospitalization summarizes the current episode as it appears on the Initial Psychiatric Evaluation form

Evaluations

The evaluations element includes the following:

Lists the evaluation and assessment procedures during hospitalization, specifying the impact on treatment and follow-up on abnormal results

Includes, as appropriate, any tests
Examples
: Psychological testing, laboratory testing, radiologic tests, EEG, EKG, nuclear medicine testing, special dietary

Clinical Findings

Clinical findings includes the following as a result of the patient's stay:

Summarizes the patient's progress in behavioral terms, addressing progress on treatment plan goals and objectives as observed chronologically in the progress notes.

Clinical findings includes the following as a result of the patient's stay:

Documents use of medications and results

Condition at discharge

Condition on discharge includes describing the patient's mental and physical condition on the day of discharge in behavioral terms compared to that of admission.

 

Discharge diagnosis

When a diagnosis has been made, document diagnostic codes and diagnosis for each axis as follows:

Uses DSM-IV TR Plus code numbers and terms following DSM-IV TR Plus instructions

On Axis III, includes any significant conditions identified

Terms not to use: Deferred, rule out, history of, versus

Discharge and aftercare plan

This table describes the discharge and aftercare plan:

Plan Part

Description

Medication and appointments

Dictates medication prescribed to the patient at the time of discharge

Level of activity

Notes the level of activity expected of the patient upon discharge including requirements and restrictions

Diet on discharge

Notes any dietary needs of the patient upon discharge, including requirements and restrictions

Attending physician signature

The attending physician signs his/her full name of the discharge attending physician followed by degree initials.

Related standards

The Joint Commission : Provision of Care

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Harris County Psychiatric Center University of Texas Health Science Center