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Discharge Summary - The Discharge Summary is a document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting. It provides information for the continuation of care following discharge.
Inpatient care is the care of patients whose condition requires admission to a hospital. Progress in modern medicine and the advent of comprehensive out-patient clinics ensure that patients are only admitted to a hospital when they are extremely ill or have severe physical trauma. [1]
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
Poorly co-ordinated discharge from hospital is having an effect on patients’ satisfaction with NHS care, a survey has found, with some saying they do not feel involved in decisions and are not ...
This can include discharge/transfer orders, pharmacy orders, radiology results, laboratory results and any other data from ancillary services or provider notes. [65] This type of event monitoring has been implemented using the Louisiana Public health information exchange linking statewide public health with electronic medical records.
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
Discharge planning processes can be effective in reducing a patient's length of stay in hospital. For example, for older people admitted with a medical condition, discharge planning has been shown to improve satisfaction, reduce the overall length of stay, and within 3-month period reduce the likelihood of readmission. [4]
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