Each student will prepare a patient discharge summary for a patient case based on the students recent clinical experience. The patient’s diagnosis should be pertinent to the current semester; the patient must be transferred or discharged. Students will write a complete discharge summary as part of the permanent medical record. The case-written discharge summary must be submitted with less than a 20% match on Turnitin/AI detection software.
The following information should be included in a discharge summary:
- Patient name, MRN (use only age, sex (gender), and race); e.g., 58-year-old Hispanic male.
- Reason for admission:
- HPI
- Other pertinent history
- Hospital stay: Review what occurred In chronologic order
- PMH and PSH
- Pertinent family history
- Social history
- Allergies
- Medications
- ROS
- Summary of VS and most recent PE
- Lab data (pertinent to discharge)
- Imaging
Comprehensive Plan with timeline addressed by problem
- Cardiovascular
- Respiratory
- Neuro
- ID
- GI
- Heme
- Any others
- Economic Stability: Employment, income, expenses, debt, medical bills, and support
- Education: Literacy, language, early childhood education, vocational training, and higher education
- Social and Community Context: Social integration, support systems, community engagement, discrimination, and stress
- Health and Healthcare: Access to healthcare, health literacy, insurance coverage, and quality of care
- Neighborhood and Built Environment: Housing, transportation, safety, parks, playgrounds, walkability, and access to healthy foods
Be sure the discharge plan is high quality. Use the Agency for Healthcare Research and Quality (AHRQ) discharge planning checklist titled IDEAL so all required aspects of discharge are addressed:
- Include the patient and family as full partners in the discharge planning.
- Discuss 5 key areas:
- Describe what life at home will be like.
- Review medications.
- Highlight warning signs and problems.
- Explain test results.
- Make follow-up appointments.
- Educate the patient and family in plain language.
- Assess understanding of explanations from all disciplines.
- Listen to the patient and family and honor their goals and preferences if possible.
Follow the outline in the grading rubric to organize the discharge summary paper. The length should not exceed 12 pages, using APA Style (7th ed.).
Get fast, custom help from our academic experts, any time of day.
Place your order now for a similar assignment and have exceptional work written by our team of experts.
Secure
100% Original
On Time Delivery