Discharge Summary And Plan: Fill & Download for Free

Let me give the answer from a doctors perspective.Although most doctors including me find record keeping boring, it is a vital part of a doctors life.Doctors may end up spending 30-50% of their working hours writing case records or typing them in a computer, writing drug charts, drug indents, insurance forms, discharge summaries and many more essential paper work.Some of the work is duplicated as multiple records are needed to be maintained.Why is it important to maintain recordsRecords are a proof that you have managed the patient properly. There is a saying “If it not recorded, it is not done. “Records provide continuity of care. Doctors and nurses cannot continously work in the hospital, they work in shift and case records help them in guiding a patients treatment by informing them about the patients status over the preceeding hours, days to years.A doctor puts his thoughts and plans in the record. This guides a patients treatment.Obviously in legal problems records are very important. Records that are not signed, dated or have corrections that seem illegal are not valid.Records are important for research. They provide data for doing studies.Records are important for summarizing a patients condition for providing discharge summaries and insurance reports.Records are needed to look at the quantum of work done by the doctor and the department. Future expansion and funding depends on the amount of work you do.Record are needed for the safety of the patient.In high income countries medical transcription and audio recording of notes is common. Although this can be expensive as it requires more staff and technology. Majority of Indian doctors still rely on their mighty pens and unique code words to enter their findings in a case sheet.

Important question.Always ask a copy of discharge summary and reports at discharge.Check that your name and hospital ID on reports match your name.Ask the nurse or doctor administering the medicine what they are giving to you and is it intended for you. Human error is possible, you may end up getting the wrong medicine. This is especially true if patients have same names.Ask the staff to use handrub or wash hands with soap before touching you or your instruments. This will reduce hospital acquired infections. Hospital infections are caused by dangerous resistant bugs and can kill you.Ask the doctor or nurse to change your medication schedule so that you are not disturbed unnecessarily in middle of the night. Most of the times we can do it.If you are planning to get discharged ask the staff to initiate it a day before so that you can go home next day morning. Many times a discharge initiated in the morning means you can go home only in the evening and you get billed for one more day in the hospital.Check your bills thoroughly. You may be billed twice for the same consumable or procedure. Ask the staff to return or refund unused consumables.Ask relatives and friends to avoid visiting you in the hospital. Overcrowding increases hospital infections and also reduces cleanliness. They can see you once you are back home.Always carry a copy of your insurance card with you, it may be useful in emergencies.If you don't like the hospital food, discuss with your doctor about bringing home cooked food, most would agree.Learn to look at the monitors you are connected to. Ask the nurse or doctor what are the normal parameters in the monitor and when should you call the staff if something abnormal comes in the monitor.Don't forget to pack your toothbrush, paste and other toiletries. Don't wear valuable jewelery when getting admitted in hospital. Don't leave your phone or electronic items unattended in your room.

I don’t speak as well as a few years before, having at one time given a paid address to hundreds of people. Writing has never flown from the depths of my creative inner self, like the prose of a woman writing to her distant lover. Nevertheless, perseverance has at least brought volume.I am trained to think like a scientist, clearly, concisely and with a view toward accuracy. It’s difficult to break a pattern developed through years of study,research, writing papers and later assessments, treatment plans, treatment notes, discharge summaries, and letters of recommendation for college students.The CDC required four professional narratives during the year’s internship, leading up to a permanent appointment. If you were good, with some luck, a paper might be published. My final narrative, written under the advisement of a public health physician, became the published standard for drug treatment for STD’s in Los Angeles County.