Hospital Discharge Summary: Fill & Download for Free

Your test reports belong to you. By law the hospital has to provide you with a copy of your reports.Not only reports but patients have a right to get a copy of their treatment details and discharge summary as well.You can write a formal letter to the medical superintendent or CEO requesting for a copy of your reports.https://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/patients-have-right-to-get-medical-records-from-hospitalssays-law-ministry/articleshow/40588458.cms

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.

After an uncomfortable stay in a psychiatric hospital, I read my discharge summary. Instead of being only factual, it contained judgmental opinion. It also contained a diagnosis of benzodiazepine abuse! There were many other errors as well.I was shocked. I had never seen such a discharge summary, and I have never abused my medications, taking them only as prescribed. In fact, during that stay, I had been prescribed them, but had taken none and also had a negative urine test!I spoke to both my general practitioner and psychiatrist about the document, and they were not happy at all. My GP said it was if she wasn't even reading about her patient.I wrote a letter to the psychiatrist in charge of the summary, outlining my reasoning, and he refused to change anything.I wrote two letters to the ombudsman for the hospital sector, and he suggested I write an opinion to be included with my files. That was insufficient, because generally patients are not believed over doctors.Then, my psychiatrist wrote a long letter detailing why he was not in agreement with the summary, and he requested a round table with the psychiatrist and his boss and the ombudsman.The ombudsman arranged the meeting.Before the meeting, I was contacted by the ombudsman, who told me that the director of the hospital had called him to tell him that all errors I had noticed would be fixed, and a new summary written. We would still have the round table discussion to determine what my stays would look like in the future, to prevent any more problems.I went to the meeting, and the psychiatrist’s boss, another psychiatrist who had treated me in the past, was there. He apologized multiple times, and we made arrangements for me not to have to see the erring psychiatrist during future stays.By the way, this good psychiatrist is Dr. med. Thomas Reisch, and he has some great published papers on understanding suicide, borderline personality disorder, and other mental health issues. Google Scholar