Discharge summary

  • Client Name: Client ID#: Discharge Date: Admit Date: Date of Last Face to Face: Discharge summary is among the four types of reports that comprise the core of medical transcription work and is required whenever a patient is discharged from the hospital. 1. It also contains a medication care plan for the patient after they are discharged from the hospital. 1957 Date of Admission Date of Discharge Status 01. You were treated for deep vein thrombosis . M. 7. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with a past medical history of hypertension, anemia, and goiter who presented with one-day history of sharp right upper quadrant and epigastric pain and dyspnea. Discharge Summary An information guide Discharge Summary Key message When you leave hospital, you should have a discharge summary given to you. The discharge summary is viewed as the synopsis of all events during the patient's stay. He needs a discharge summary. Discoordinate twin. POLICY: A. An essential part of this process is the documentation of a discharge summary. The eDischarge Summary  The Discharge Summary Template approved by the Health Authority Medical Advisory Committee (HAMAC) provides a standard framework for physicians to  As an intern I thought how laborious it was to churn through endless discharge summaries, and start every letter “Dear Doctor, thank you for your ongoing care and  One of the areas currently being addressed is the development of a clinical discharge summary data set. Brevity and summary. Circumstances. OUTPATIENT SUMMARY REPORT SAMPLE #3 DATE OF SURGERY: The best practice for a Discharge Summary is to include the discharge disposition in the display of the header. Collection of most popular forms in a given sphere. DATE OF ADMISSION: MM/DD/YYYY. PCP: (must  The Agency's discharge summary specification supports a national standard for electronically capturing details of a patient's hospital stay in a structured format. o Course of illness/treatment or therapy AODA DISCHARGE SUMMARY (CVCTF Draft form) Offender Name DOC # Date of Birth Rotta, Randy 80599 02. wwdproviderstandard” – choose WWD Adult Discharge Summary. It is often the primary mode of communication between the hospital care team and aftercare providers. PROCEDURES PERFORMED: Laparoscopic right colectomy. Do include details of follow up appointments , and ensure the patient is aware they need to follow up with their GP. Discharge Summary 4. Clarity. Prolonged premature rupture SAMPLE Page 1 of 3 Printed by: Snow, Mike on 15-OCT-2015 GENERAL INTERNAL MEDICINE DISCHARGE SUMMARY Patient Name: Smith, John MRN: 1234567 DOB: 25-Dec-1950, 65 years old Discharge Summary A discharge summary is an account of the major events of the hospital admission for the patient’s GP, so they can take over the patient’s care. A new discharge summary and process for dictation has been designed to comply with the. 1. To support this information sharing the establishment of a national standard, fully structured, coded electronic message to convey information from an Emergency Care department to a GP Practice is in progress. Baseline measurement revealed significant room for improvement. Rotta was recommended for treatment by an A & B assessment. Information related to the discharge summary . The summary may include the reason for hospitalization, procedures performed, the care, treatment and services provided, the patient's condition The Discharge Summary Form makes it official. The aim is to make the  9 Nov 2018 An overview of the Transfer of Care Initiative which dictates the standards that emergency care discharge summaries need to conform to. As the name suggests, it is a summary of the entire hospitalization from   Fillable Discharge Summary Template. It contains important information about your hospital visit, including: The Discharge Summary Template approved by the Health Authority Medical Advisory Committee (HAMAC) provides a standard framework for physicians to consistently and effectively complete and communicate critical patient care information. Intrauterine growth restriction. This website has been developed to provide doctors with a powerful tool for writing accurate and concise discharge summaries in a fraction of the time it would  Discharge summary. A discharge summary is a   20 Aug 2018 As an Advances in Patient Safety report notes, "Hospital discharge summaries serve as the primary documents communicating a patient's care  discharge summary. For hybrid records, identify portions of the record that are maintained within the data repository and not printed as a hard copy record Refer to section 4. How to abbreviate Discharge Summary? The most popular abbreviation for Discharge Summary is: D/S This is the case study used during the “Your Medical Documentation Matters” presentation. Start a free trial now to save yourself time and money! Pediatric Discharge Summary Medical Transcription Sample Report. Discharge summary is a document that contain a simple summary of the patient’s health information and their time at the hospital or facility. Pathology from the biopsy showed invasive moderately differentiated Everything in the CoPs and Interpretive Guidelines states the reason for the discharge summary is to provide essential information to the patient’s next healthcare provider (typically the community physician or clinic staff) who will provide follow up care after the agency discharges the patient. The nurse in charge will give . Amit Shah, University of Texas Southwestern Medical Center at Dallas 1) JUST DO IT! Get it done, at the moment of discharge—while you are writing the scripts, arranging follow up, etc. dis·charged , dis·charg·ing , dis·charg·es v. Posted: May 1, 2018. Your healthcare providers will help you create a care plan to use at home. 15 04. It can be a few brief paragraphs or a multipage report, depending on the complexity of the patient’s condition and treatment. This will not be Start studying Discharge Summary. A Discharge Summary provides an overview of a patient’s hospitalization from admission through discharge. MRN: 1234567. The plan will give directions on how to prevent or manage shortness of breath. The hospital must have an effective discharge planning process that focuses on the patient 's goals and treatment preferences and includes the patient and his or her caregivers/support person(s) as active partners in the discharge planning for post-discharge care. 3 – Audits and Quality Monitoring. Available for PC, iOS and Android. COPD (chronic obstructive pulmonary disease) can get worse quickly. 05. Discharging patients from a hospital is a complex task. The discharge summary provides a synopsis of the patient’s clinical history while in the hospital. MEDICATIONS AND FOLLOWUP: As per Dr. Fill, sign and send anytime, anywhere, from any device with PDFfiller. The basis for the discharge summary Transitions of Care – How to Write a “Good” Discharge Summary By Kimberly Dodd, MD Imagine the scenario… It’s 12:30 P. 2. Patient Name: Russell Johnson Medical Record Number: 123456789 Admission Date: 08/01/14 Discharge Date: 08/05/14 . This can be made a button on discharge order set. Manitoba midwives work in northern and remote communities, southern and rural communities, and in urban areas. It is a tool used for reviewing the details of the case during the presentation and the documentation . would suggest a renewed need for CCS Services: Barriers to quality. The emergency care discharge summary project is closely aligned with t he interoperable eDischarge Summary Standard, which includes information models for key str uctured and coded data on diagnoses, procedures, allergies and medications [see related documents 3] Newborn discharge summary. Your support and care can have a significant effect on a persons recovery; Stay informed about their health condition/s, medications  'Planning your discharge from Hospital Booklet' GUH. Pediatric Discharge Summary Medical Transcription Sample Report #1. It highlights important Federal and State Medicaid documentation regulations and rules. 2 Oct 2019 As a leading provider of medical indemnity insurance to general practitioners, Tego understands the importance of a discharge summary and  Discharge summary is a document that contain a simple summary of the patient's health information and their time at the hospital or facility. The discharge summary is the major vehicle for communicating post-discharge patient information from the hospital to primary care physicians. This profile builds on C-CDA on FHIR US Realm Header. The last step when discharging a patient from the hospital is to write a discharge summary. ACTIVITY: Pelvic rest for 6 weeks and nothing inserted into the vagina for 6 weeks, i. dehydration, respiratory distress, ©2017 Magellan Health, Inc. Patient discharge times vary somewhat. discharge summaries: A discharge summary is required for vaginal deliveries with a post delivery length-of-stay greater than two days, or any length-of-stay coupled with a complication. and you have clinic scheduled in 45 minutes. Discharge Summary The last step when discharging a patient from the hospital is to write a discharge summary . A mortgage is discharged if it has been carried out to the full extent originally contemplated or terminated prior to total execution. 20(l)). Trust's requirement for a 24 hour turnaround. I want to share some thoughts on the contents of my latest discharge summary from hospital and some implications that have become apparent. The discharge summary is one of the most critical documents in medical care settings. DISCHARGE SUMMARY . PURPOSE: To provide guidelines for the completion of discharge summaries. It is important that the discharge summary is just that--a summary of events already chronicled in the patient's record. A discharge summary is a clinical report prepared by a health professional at the conclusion of a hospital stay or series of treatments. 1 Table 1 Legal Source Legend for the hybrid record. All C-sections require a discharge summary. Patient's Name*: b. Clinician's Narrative, and 4. All the information is  25 Jun 2012 When a patient is discharged from a hospital, a discharge summary or clinical résumé to document the care provided to the patient during his or  There was an urgent need to improve patient safety and continuity of care by developing standardised e-discharge summaries. Everything in the discharge […] Midwifery in Manitoba. COVID-19: POST-DISCHARGE CARE A Rapid Guidance Summary from the Penn Medicine Center for Evidence-based Practice Last updated March 26, 2020 6:00 pm All links rechecked March 26 unless otherwise noted. R. You opened the discharge summary when she came 3 ways to abbreviate Discharge Summary updated 2020. To liberate or free; to terminate or extinguish. Learn more about the importance of a proper discharge by reading "Wheel of Fortune - Part 8. Inaccurate or  Discharge summary from hospital. All the information are written concisely. 01. Discharge Summary . 11 Jan 2017 Assessment of hospital inpatient discharge summaries, written for general practitioners, from a department of medicine for the elderly service in  Click on the thumbnail to view a larger image. 24. High risk behavior. discharge summary A document prepared by the attending physician of a hospitalized Pt that summarizes the admitting diagnosis, diagnostic procedures performed, therapy received while hospitalized, clinical course during hospitalization, prognosis, and plan of action upon the Pt's discharge with stated time to followup Aug 20, 2018 · A discharge summary plays a crucial role in keeping patients safe after leaving a hospital. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old female, who on a screen1ng colonoscopy, was found have a friable polyp in the ascending colon. Donna Donna Kent, RN, BSN, CCDS Heart attack - discharge. §483. 15 Completed w/ Aflercare Therapist Name 1 Agent # Ms. We will also have her continue with low-fat diet until she is cleared by her primary care physician. Inadequacies of the Traditional Discharge Summary. 3. Timely. This thing type describes the discharge summary of a person  Aim To estimate the rate of failures in processing actions requested in hospital discharge summaries, and to determine factors associated with these failures. Publicly funded and regulated midwifery was introduced to Manitoba in June 2000 with the proclamation of the Midwifery Act. II. She needs RTC level of care. Since that time, midwives have provided health care for thousands of Manitoba families. But what if we took a step back and  Timely Discharge Summary delivery to subsequent care providers reduces adverse events post-discharge by 20%. We use cookies to understand how this site is used and to improve the site to make  Discharge Summary Importance. Your doctor makes his rounds in the morning and confirms that you can be discharged. • A recapitulation of the resident’s stay that includes, but is not limited to: o Diagnoses. Patients medical/   Patient Discharge form Template Inspirational Discharge Summary Templates 4 Samples to Create Invitation Templates Word,. Quick reference guide. SNF Discharge Planning; A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility (42 C. There was a screen shot but it seems Lyris will not let me add. The first paragraph of the letter starts: “Anthony Murray, 37-year-old male, resident of Woy Woy, et cetera” followed by a short rundown of admittedly indispensable vital statistics, yet it’s followed by two of the most inventive pages of literature Quality of documentation is harder to quantify and incentivise, but it has a significant impact on patient care. A discharge summary can make the transition from hospital to home much safer and smoother for patients. Overview. Good discharge summaries facilitate continuity between secondary and primary care. Discharge Summary: A clinical report prepared by a physician or other health professional at the conclusion of a hospital stay or series of treatments. ADMITTING DIAGNOSES: 1. Doe. Ascheim DD, et al. 6. Galway University Hospitals 'Planning your discharge from Hospital Booklet'. eRecord and Discharge Summary Reports Below is an overview of the reports most community providers are receiving when their patients are discharged from Strong and Highland hospitals. … session, the re-evaluation(s) that may be required, and the discharge summary. Date of Admission: Date of Discharge: Attending Physician: (should be the attending on the day of discharge). A discharge summary is a handover document that explains to any other healthcare professional why the patient was admitted, what has happened to them in hospital, and all the information that they need to pick up the care of that patient quickly and effectively. BHS/SUD, F701 Page 1 of 2 July 2019 . However, given the discharge summary’s pivotal communication role in care transitions, even a small frequency of omitted patient discharge condition information is a concern and may affect patient safety. Progress Note and Discharge Summary No the Discharge summary is enough. DATE OF DISCHARGE: MM/DD/YYYY. This is a condition in which a blood clot forms in a vein that is not on or near the Provides the information needed to be compliant with the elements required (F661) for the Discharge Summary when a resident is discharged from a LTC facility. 68 18842-5Discharge summaryActive Part Description LP72467-1 Discharge summary note Discharge summary is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. PDF 1. 08. We measured the quality of 10 Briggs Form 3017 provides your facility with a complete summary of a patients condition upon discharge. Back 8 1/2" x 11", white paper, blue ink, padded in 100s. A 28-week gestational male, twin A. Discharge Diagnosis*: Make sure this is a diagnosis and not a symptom or sign. Standard Contents of Discharge Summary Format: a. : 903321 Discharge Date: 03/30/- - - - Page 2 The patient was discharged on postoperative day number three after having had a normal bowel movement. Discharge Summary SUD 2017. As an Advances in Patient Safety report notes, "Hospital discharge summaries serve as the primary documents communicating a patient's care plan to the post-hospital care team. Physicians use their  15 Oct 2015 GENERAL INTERNAL MEDICINE DISCHARGE SUMMARY. … supervision of) the PTA, the status of the patient, and any observations the. Demographics Patient o Name. Based on a  Turnaround time was recorded from discharge intimation to final summary signed by concerned doctor in order to calculate and study the cause of delay. WiTheim-Copas, CSAC 32006 COURSE OF TREATMENT: Mr. Should the patient have a new or recurring episode, the process begins again. Health Advocates. Description of Profiles, Differentials, Snapshots, and how the XML and JSON Nov 09, 2018 · The Emergency Care Discharge summary must currently be issued to GP practices within 24 hours following a patient's A&E attendance. DISCHAGE SUMMARY Date of Exam: 7/4/2012 Time of Exam: 7:14:10 PM Patient Name: Anna Smith Patient Number: 1000010544165 DATE ADMITTED: 3/12/2012 DATE DISCHARGED: 7/4/2012 This discharge summary consists of 1. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the Title: RECREATION THERAPY DISCHARGE SUMMARY Author: Rehab Last modified by: Charles Dixon Created Date: 8/12/1999 11:43:00 PM Company: WVDRS Other titles Version 2. What is a discharge summary? A discharge summary is a letter written by the doctor  1 Jan 2020 Discharge summaries, often considered the bane of every junior doctor and ED physician's existence. Events, diagnoses, and assessments should not be recorded for the first time in the patient's discharge summary. She was discharged without complaints on no medications. The discharge summary is one of the most critical documents in medical care settings, but it is pron. Patient Name: Smith , John. Creating a better discharge summary. The Initial Assessment, 2. • The Discharge Summary is  14 Aug 2018 Abstract Rationale One of the key functions of the discharge summary is to convey accurate diagnostic description of patients. 3,4 Inadequate communications and deficiencies in information transfer at Complete a discharge audit focusing on those elements outlined in discharge analysis in section 4. After an initial A discharge summary is a physician-authored synopsis of a patient's hospital stay, from admission to release. This note will summarize his hospital course, from initial presentation for an outpatient procedure, to a catastrophic complication, and finally intensive care unit admission. Attending Physician: Dr Gary Marshall MONTANA STATE HOSPITAL POLICY AND PROCEDURE DISCHARGE SUMMARY Effective Date: May 20, 2014 Policy: HI-04 Page 1 of 3 I. Commission discharge summary component standards. Resident records should contain a final resident discharge summary which addresses the resident’s post-discharge needs (42 C. no tampons, douche or sex. DIET: Advance as tolerated. DISCHARGE SUMMARY SUMMARY OF TREATMENT PLANNING: This discharge is at the family's request. discharge summary synonyms, discharge summary pronunciation, discharge summary translation, English dictionary definition of discharge summary. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Fill out, securely sign, print or email your PHYSICIAN HOSPITAL DISCHARGE SUMMARY. Identifying patients requiring a discharge summary can be done in two ways, using EDS or using Digital. All the information is written in a brief and concise point. 43 Condition of participation: Discharge planning. v. jpg (101042 bytes) Kalib's discharge summary page 2. 01 DISCHARGE SUMMARY The provider shall complete a Discharge Summary within 30 calendar days of the last face to face treatment contact for any beneficiary with whom the provider lost contact. Date of Admission/Transfer: Date of Discharge/Transfer: Admitting Diagnosis: This should be your working diagnosis at the time of admission (not the chief complaint/presenting symptoms). A Discharge Summary is a report containing a description of a patient's hospital stay, diagnoses, interventions performed and recommended next steps. She tries to explain to him why he can't do that because of the global period but he says that he can because, well, the Discharge Summary/Transfer Note/Off-Service Note Instructions. Any forms of ambiguity are avoided for understanding. Simple. The discharge summary is a vital tool for transferring information between the hospitalist and primary care physician, but it isn’t always given the priority it deserves. This policy, or summary of the policy, will be publicly available by posting to the hospital web site and a copy of this information will be provided to the patient at admission and at discharge. As the name suggests, it is a summary of the entire hospitalization from arrival to DISCHARGE INSTRUCTIONS: Call for increased pain, fever or increased bleeding. Top 5 Discharge Summary Tips By: Dr. The first paragraph of the letter starts: “Anthony Murray, 37-year-old male, resident of Woy Woy, et cetera” followed by a short rundown of admittedly indispensable vital statistics, yet it’s followed by two of the most inventive pages of literature Discharge Summary Medical Transcription Sample Report Emergency Room (ER) Medical Transcription Transcribed Sample Reports Endocrinology Medical Transcription Transcribed Consultation Sample Reports Define discharge summary. This profile was published on Thu Dec 08 06:39:19 AEDT 2016 as a draft by Lantana Consulting Group. The patient has improved, but is at high risk for relapse. A discharge summary from the neonatologist is required for any newborn who has a Discharge Summary DISCHARGE DIAGNOSIS: T1NOMO adenocarcinoma of the colon. Discharge Status and Instructions DISCHARGE MEDICATIONS: The patient was discharged home taking Darvocet-N 100 for pain and Omnicef 300 mg one tablet twice daily as a prophylaxis against infection. Saved from topofthepileresumes. We will discharge her home today on Flonase, loratadine and have her follow up with her labs in approximately a week and have her discuss these results with her primary care physician. The. The effects of its absence perhaps best define its importance: delayed discharge summaries are associated with a substantially increased risk of hospital readmission by 50% or more. This report is critical for further consultation and promoting patient safety while they transfer from care settings. It outlines   Discharge Summary Form Mobile App - This form template covers admission and discharge dates, diagnosis, and discharge condition, procedures, brief HPID, When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the  For patients who will give go home after extensive days in the hospital for treatment or surgery must have a discharge summary form to have the outline of all the  The Crib Notes™ Discharge Summary is a special type of Progress Note that combines the admission summary and exam, problem-oriented summaries and  discharge summary : discharge report summarizing a mandated period of care. Considered the  Discharge Summary: A clinical report prepared by a physician or other health professional at the conclusion of a hospital stay or series of treatments. doc - wiki siframework instantly   interpretation of the terms in the documents and the information provided is uniform. F. There is no need to document on the progress not unless the provider just wants to note the date and then see discharge summary and signature. The case manager informs you that Mrs. Seggerman Hospital No. 14 Mar 2017 Summary. Same as 1. Inpatient Reports. When a patient is discharged from secondary or tertiary  If you've been hospitalized, your discharge summary records will include everything noted about your stay, including your diagnosis, test results, and procedures  Goals of a discharge Summary: 1. 508C, Provider Medical Discharge Summary Author: BlueCross BlueShield of Tennessee Subject: Provider Medical Discharge Summary Keywords: Provider Medical Discharge Summary Created Date: 5/8/2018 3:00:04 PM Discharge Summary. Jones just got a bed at Goddard House and the ambulance is booked for 1:30 PM. rev. The patient easily was very depressed and anxious with paranoia. IDENTIFIED PROBLEMS/OUTCOMES: 1. That documentation is what is dictated and is a part of the medical record. , Often, the discharge  Discharge Summary Template. When you leave hospital, you should have a discharge summary given to you. e. Ob-Gyn Discharge Summary Medical Transcription Sample Report #3. DOB: 25-Dec-1950, 65 years old. Discharge summaries should be dictated, not typed whenever possible. Course of Treatment, 3. requirements for the various provider types furnishing services. Kalib's Discharge Summary Page 1. 2. tr. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. 18 Jun 2015 New research under way at University at Buffalo School of Nursing could lead to automating hospital discharge communication and reducing  Learn more about discharge summary templates, how to write them, and how to fill out the form. Write in narrative form; include current alcohol and other drug use, living situation, legal status/criminal activity, Discharge Summary Template Date of Admission: Date of Discharge: Attending Physician: (should be the attending on the day of discharge) PCP: (must include the name of the PCP or clinic, “out of town” not acceptable) Admission Diagnosis: This should be the reason for admission (e. In the emergency room: (Additional Requirements) 1. It's a communication tool that helps clinicians outside the hospital understand what happened to the patient during hospitalization. Jan 01, 2020 · Don’t just copy-paste your ED assessment into a discharge summary – take the time to summarise the case – it may also present a useful learning opportunity to synthesize the information. My patient's family had the body taken away this afternoon, but he is still under my care. 11/17 Discharge Summary Reason for termination (was patient in agreement with termination at this time): If patient did not return for scheduled appointment, were attempt(s) made to contact DISCHARGE SUMMARY Patient Name: Brenda C. g. " Order your set of forms, personalized for your practice today. 10 Aug 2017 Root element: discharge-summary. The provider must develop a discharge summary for each participant and provide a copy to the CRS program staff member within 10 business days after services are completed or terminated. A discharge summary is a kind of document which has all the necessary details about the health condition of a patient and their time in a hospital. Hospital  Because the doctor has not yet received the patient's discharge summary, he has no way of knowing the results of the endoscopy she had in the hospital. Fill out, securely sign, print or email your Obstetric Discharge Summary - Login instantly with SignNow. Depression. jpg (66218 bytes)  Arrange the issue of a discharge summary to the patient's GP and referring doctor at the time of discharge, with a copy given to the patient / carer. 15 Page 2 of 2. that . Did you know? The Discharge Summary is the most important document in the medical record. A discharge is the act or instrument by which a contract or agreement is ended. A document prepared by the attending physician of a hospitalized Pt that summarizes the admitting diagnosis, diagnostic procedures  The discharge summary is a vital tool for transferring information between the hospitalist and primary care physician, but it isn’t always given the priority it  Hospital discharge summaries serve as the primary documents communicating a patient's care plan to the post-hospital care team. Discharge. Apr 06, 2020 · A friend of mine works for a vascular surgery practice and one of the surgeons she works for keeps trying to bill 99234-99236 when he discharges a patient he operated on. GI Medical Transcription Discharge Summary Sample Report #4 CHIEF COMPLAINT: Right upper quadrant pain and dyspnea. Not only will it be much quicker, but you are much less likely to make mistakes (medications, follow-up, etc). What is a discharge summary? A discharge summary is a letter written by the doctor caring for you in hospital. When a patient is discharged from either Strong or Highland hospitals, you receive four faxed reports. Introduction Discharge Summary Templates. Treatment Summary. The discharge summary must include: the strengths, abilities, needs and preferences of the participant; the goals established in the Individualized Program Plan; Deep vein thrombosis - discharge. 4. The junior doctors' forum led this project to improve the quality of electronic discharge summaries (eDS). It outlines the patient's chief complaint, the diagnostic findings, the therapy administered and the patient's response to it, and recommendations on discharge. At on the follow-up to 2007 Discharge Decisions (Summary)-European Parliament Resolutions drafted pursuant to Article 276(3) of the EC Treaty and Article 180b of the Euratom Treaty, [] Article 147 of the Financial Regulation and Article 119(5) of the EDF Financial Regulation DISCHARGE SUMMARIES ARE TO BE COMPLETED IN THE EMR BEFORE THE PATIENT LEAVES THE HOSPITAL A Template was created (which includes PPOC statements and durable equipment attestation) to assist in completion of discharge summary: “. 12(a)(7)). 1 thru 1. DATE OF ADMISSION Therefore, it matters not whether the diagnosis is ‘repeated’ or ‘mentioned’ in the discharge summary, and this is why, in general, charts are coded, dropped, and billed, even if the discharge summary is not yet dictated or transcribed. § 482. o Hospital number o DOB o Address o GP details Hospital stay o Consultant o Ward & hospital o Admission and discharge date o Discharge destination A PTA may provide clerical assistance with a discharge summary. discharge summary

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