Clinical Discharge Summary



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Medical Staff – 5.24.2016 Talk Ten (ICD 10) Tuesday Tips….Got a Minute: Specificity: noun spec·i·fic·i·ty ˌspe-sə-ˈfi-sə-tē the quality or condition of being free from ambiguity Discharge Summary Template…Capture it all ADMITTING DIAGNOSIS (Reason for hospitalization): DISCHARGE DIAGNOSIS (Significant findings: all conditions resolved/all possible and probable diagnoses stated earlier in record/Rule it in/Rule it out or Resolve it ): HOSPITAL COURSE (Procedures performed and findings/Surgical findings/Test results (include any pending or sent out labs not resulted yet)/ Treatment rendered, Description of initial diagnostic evaluation): REFERRING PHYSICIANS/CONSULTS: DISCHARGE CONDITION/DISPOSITION: Patient sent (Home/ECC/LTC) in (Good/ Fair/Guarded/Poor) condition..




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