Nursing Discharge Summary Hospital Forms: 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.

Three years ago, a doctor put a stethoscope on my heart and said “you have a murmur.” It was a few days before a major surgery so they sent me to cardiology for an echo. The result was undetermined because the technician failed to get a clear picture of the heart. None of this particularly bothered me; I had a murmur at birth that I grew out of by age 12. Heart problems are rampant in the family, yet we (especially the women) survive to a normal lifespan (80–90). I went through with the surgery without incident.Two months later I returned to my home, far from the hospital, and saw my PCP for followup. I told him the hospital found a murmur, and referenced the family history of good outcomes with annual monitoring and sometimes beta blockers. My doctor listened and said he didn’t hear a murmur. Knowing that hearing the murmur may have been random chance, the stress of surgery, or a mistake, I thought little more of it as I focused on recovery from the surgery.For the next three years, I told the various dentists, ER docs, surgeons and nurses that I had no heart problems. Never checked the box on the form(s). Meanwhile, I saw my PCP about every three months or so. Each time, he’d ask to listen to my heart. I’d say, “sure, you hear anything? “No, there is no murmur.” Okey dokey.Last year I was discharged from a hospital and received the usual handful of educational materials and a discharge summary. I read the summary and it had no surprises. Then I lost it. So, I contacted my PCP and asked for a copy. He sent it.That discharge summary was quite different than mine. The doctor’s copy included information about the tricuspid regurgitation from a valve problem. This matters because heart damage, specifically, the tricuspid regurgitation, can be a result of another disease process I’m being tested for. I would never have known to disclose this pertinent info to the specialist if I hadn’t seen the doctor’s copy of the discharge summary.Moral of the story: Doctors keep two files—one is the truth in their professional judgment, while the Patient Copy is the bs they feed patients to get them out the door.In a recent discharge (don’t ask . . .) another doctor I’ve never met before was giving me a once over before I left. After she listened to the heart, I asked if she heard a murmur. She said yes, and I asked why she didn’t tell me. She said “We often don’t tell patients about conditions we can’t fix.”So, this seems to be a well-established policy. A lie about your heart condition is cool if that doctor can’t fix it. This can’t be ethically defensible, in my opinion, yet the last doctor was so open about it that it must be common among the medical profession.Edit#2 UPDATE—Last year I had stroke-like symptoms while sitting next to an RN in front of 50 other people. I lost consciousness and was carried out to a hospital where symptoms were recounted by witnesses. I spent 5 days in the hospital, which the hospital doctor said was the most high risk time for re-stroke or heart attack. Then discharged home.My online medical records indicated a stroke diagnosis and that’s what my insurance paid for. So, thats what I’ve included in med history.Problem: No evidence of a stroke. And that wasn’t the real diagnosis.A few months later, while working at a different city, I noticed neuro problems resurfacing in my speech and a colleague took me to that local hospital. I was observed overnight, felt fine and discharged. Before I left, the ER doctor sat down to chat. He said “I’ve read all your records from your 5 day hospital stay and every page of (an earlier different) Premier Medical Center workup.” I braced for bullshit but he said, “You need another doctor.” I stared. He repeated “You need another doctor. It will take time to find the right one, but you must find another one.” He said he couldn’t because he was “just a family medicine physician” and, essentially, I was out of his league. And I didn’t live there. He strongly implied that I was being ill-served by my PCP.I did find another doctor and am finally getting treated for the very rare disease reflected in three different tests a year earlier but not treated.The incident nagged at me so I requested medical records from the local hospital whose doc urged me to find another PCP. The local doc had consulted neurology at the hospital where I spent 5 days. That neuro said they diagnosed a complicated migraine and not a stroke. I’ve never even heard of that until a week ago, when I read my medical records with the handwritten notes, ten months after discharge for a stroke.EDIT: Hopefully, my story will help patients educate themselves about the limits of the medical information they receive. Get the whole file—not just what’s available in your online medical records, or what is passed off to you in a 15 min appointment.For the doctors and students who commented, thank you for taking time to offer your assurances that medicine is nobler than that. The doctor who reviewed all the records, and validated my concerns, was a new doctor who still remembered why he went to medical school. His hours reviewing medical records for a patient he’d never see again gave me hope that a specialist somewhere would care as much. Without those words of encouragement, I don’t know where I’d be today . . .

“For complex surgical procedures, you’re generally better off at teaching hospitals, which usually stay at the forefront of health research. Medical students and residents ask questions, providing more eyes and ears to pay attention and prevent errors. Teaching hospitals have lower complication rates and better outcomes.” —Evan Levine, MD, a cardiologist and the author of What Your Doctor Can’t (or Won’t) Tell You.“Those freestanding ERs popping up all over? They typically don’t have anywhere near the resources of hospital ERs, yet they cost just as much. Go there for small bumps and bruises. For something serious (chest pain, a badly broken bone), get to a trauma center where specialists and surgeons work.” —James Pinckney, MD, an ER doctor, founder of Diamond Physicians in Dallas, Texas. Check out these other 50 secrets an ER staff won’t tell you.Epidural steroid injections for back pain has risky potential complications like neurological problems or paralysis. “Generally, epidural steroid injection isn’t very useful for treatment of chronic back or neck pain,” says Steven Severyn, MD, an anesthesiologist at the Ohio State University Wexner Medical Center.No unnecessary scans. Studies have shown that radiation from CT scans could be responsible for as many as two percent of all cancers in the U.S. “CT scans are much quicker and tend to be less costly than an MRI, but does have the added radiation that MRI’s lack,” says Todd Sontag, DO, a family medicine physician with Orlando Health.Practically all surgeons have an inherent financial conflict of interest. That’s because they are paid approximately ten times more money to perform surgery than to manage your problem conservatively.” —James Rickert, MD, an orthopedic surgeon in Bedford, Indiana.No-certified specialty. If an airline told you that their pilot is the best but he’s not FAA-certified, would you get on the plane? "For the same reason, always check if your surgeon is board-certified in his specialty. Many are not.” Tomas A. Salerno, MD, chief of cardiothoracic surgery at the University of Miami Miller School of MedicineSome surgeons won’t mention procedures they don’t know how to do. "I’ll see patients who were told they needed an open hysterectomy, even though it could be handled laparoscopically. That’s one reason it’s good to get a second opinion.” —Arnold Advincula, MDYears ago, a patient sent his slides to three different pathologists and got three different answers. "I got very upset on hearing that. Now I never rely on just one pathology exam. If your doctor finds something, ask him to send your slides to a nationally recognized reference lab—not just one or two slides but the whole lot—and get a second interpretation.” —Bert Vorstman, MD, a prostate cancer specialist in Coral Springs, FloridaIn medicine, you can get a DUI, go to jail for a couple of hours, and walk out at 7 a.m. the next morning and do a surgery. "You can be accused of sexual misconduct and drug and alcohol abuse in one state and pop over to the next one and get a license. Some state medical boards don’t even thoroughly research your background; they argue that the less-than-$10 fee to access national data is too expensive.” —Marty Makary, MD.Surgeons are control freaks. "When things don’t go our way in the operating room, we can have outbursts. Some of us curse, some throw instruments, others have tantrums.” —Paul Ruggieri, MD, author of Confessions of a Surgeon: The Good, the Bad, and the Complicated ... Life Behind the O.R. DoorsMistakes are probably more common than you would think. "But most of them don’t actually hurt people. I work with residents, and I don’t let them do anything that I can’t fix if they screw it up. If there’s an error that I fix that I’m sure won’t affect the patient at all, I’m not going to say anything about it. That would accomplish nothing except to stress out the patient.” —An orthopedic surgeonSome problems just don’t fix well with surgery, like many cases of back pain. "My advice? Grin and bear it. Some surgeons vehemently disagree. They say, ‘Oh, you have a degenerative disk, and that must be the culprit. Let’s fix it.’ But many people have a degenerative disk with no pain. There isn’t a lot of evidence that we’re helping very many people.” —Kevin B. Jones, MDAlways ask about nonsurgical options and whether there’s anything wrong with waiting a little while. "Surgeons are busy, and they like to operate. A professor from my residency would say, ‘There is nothing more dangerous than a surgeon with an open operating room and a mortgage to pay.’” —Kevin B. Jones, MDTalk to your doctor about donating your blood or asking your family members to donate blood before an elective surgery. "Banked blood is a foreign substance, like an organ, and your body can potentially react adversely. If you can use your own blood or blood from your family, there’s less chance of those reactions." —Kathy Magliato, MD, cardiothoracic surgeon at Saint John’s Health Center in Santa Monica, CaliforniaResidents have to learn how to operate, and it’s required that an attending physician be ‘present'. But ‘present’ doesn’t mean he has to be in the operating room scrubbed in. At an academic institution, ask whether your surgeon will be actively participating in the surgery or just checking in every hour." —Ezriel “Ed” Kornel, MDDuring my six weeks as a surgical intern in the ER, I inadvertently stuck myself twice with contaminated needles...... briefly nodded off in the middle of suturing a leg laceration, accidentally punctured a guy’s femoral artery while trying to draw some blood, and broke up a fight between the family members of a guy who’d come in with a stab wound to the abdomen. I was slugged in the head by a delirious patient in an alcoholic rage, spat upon, coughed on, vomited on, farted on, bled on, and mistaken for an orderly.” —Paul Ruggieri, MDYour doctor should not push you to make a speedy decision about prostate cancer surgery. "Most prostate cancers are extremely slow-growing, and there is so much misleading information out there, so you should take your time.” —Bert Vorstman, MDIf you have pain in your calf after surgery, or if it swells and looks red, call your doctor right away. "Those are the main symptoms of a blood clot, which is a risk of just about every surgery.” —James Rickert, MDThis is what really keeps us up at night. "It’s not making a mistake in the operating room; it’s the noncompliant patients. When patients don’t do what we tell them, bad things can happen.” —Kurian Thott, MD, an ob-gyn in Stafford, VirginiaDon’t ask too many questions. If you ask too many questions, you can be branded as a pain in the neck. "When one extremely hostile relative bombarded me every time I walked in, I developed a tendency not to go in the room. If you have three pages full of questions, show them to the nurse. Say ‘How many of these should I wait to ask the doctor about? How many can you help me with?’” —General surgeon who blogs under the name Skeptical ScalpelAbout 25 percent of operations are unnecessary, but administrators e-mail doctors telling them to do more. "This is not an insurance company putting pressure on doctors; this is not a government regulation. This is private hospitals pushing doctors to generate more money by doing more procedures. It goes on at America’s top hospitals. The Cleveland Clinic has said this system of paying doctors is so ethically immoral that it started paying its doctors a flat salary no matter how many operations they do.” —Marty Makary, MD.Fatigue and impatience have undoubtedly contributed to some mistakes I’ve made in the operating room. "But unless you ask, your surgeon is not going to tell you that he was up all night on call before your procedure and that he may not be in tip-top form.” —Paul Ruggieri, MDI always ask at national conferences of doctors, ‘How many of you know of another doctor who should not be practicing medicine because he is too dangerous?’ "Every hand goes up.” —Marty Makary, MDVery often, plastic surgery patients don’t admit to a previous surgery, and I don’t find out until I’m in there. "I’ll go in on an eyelid or a nose, and it’s just a mess. If you don’t tell us you had lipo, there will be scar tissue, and the fat won’t come out normally. So please be 100 percent honest. There’s no need to be embarrassed. We’ve heard it all, and we don’t judge.” —Andrew Ordon, MD, cohost of the television show The Doctors and a board-certified plastic surgeon.The biggest mistake during recovery is not giving yourself enough of a break. "Give yourself time to heal. If you don’t, you can cause complications and prolong your recovery."—Andrew Ordon, MDIf your doctor wants to give you a stent, always ask: Is this better than medicine? "If you’re not having a heart attack or an unstable angina, you will do equally well with a stent or medicine, studies show. Having something permanently implanted in your body is not a risk-free proposition. There is evidence that thousands of people have had stents they likely did not need." —Marc Gillinov, MD.If I had any kind of serious medical condition, I’d go to a teaching hospital. "You’ll get doctors involved with the latest in medicine. Even for simple cases, if there’s a complication that requires an assist device or a heart transplant, some hospitals may not be able to do it. At a university hospital, you also have the advantage of having a resident or physician bedside 24-7, with a surgeon on call always available." —Tomas A. Salerno, MDBefore any operation, always ask what’s broken and how fixing it will help. "Just because you have a blockage in an artery doesn’t mean you need it fixed, especially if you don’t have symptoms.” —Marc Gillinov, MDSpecialists quietly pad your bill. “Less-well-trained physicians will call in an abundance of consults to help them take care of the patient. If those specialists check on you every day, your bill is being padded and padded. Ask whether those daily visits are necessary.” —Evan Levine, MD.Ask how to recover faster. “Since each day in the hospital costs $4,293 on average, one of the best ways to cut costs is to get out sooner. Find out what criteria you need to meet to be discharged, and then get motivated, whether it’s moving from the bed to a chair or walking two laps around the hospital floor.” —James Pinckney, MD.Second-guess tests. “Fifteen to 30 percent of everything we do—tests, medications, and procedures—is unnecessary, our research has shown. It’s partly because of patient demand; it’s partly to prevent malpractice. When your doctor orders a test, ask why, what he expects to learn, and how your care will change if you don’t have it.” —Marty Makary, MD.“Your surgeon may be doing someone else’s surgery at the same time as yours. We’re talking about complex, long, highly skilled operations that are scheduled completely concurrently, so your surgeon is not present for half of yours or more. Many of us have been concerned about this for decades. Ask about it beforehand.” —Marty Makary, MD.“Hospital toiletries are awful. The lotion is watery. The bars of soap are so harsh that they dry out your skin. There is no conditioner. The toilet paper is not the softest. Come with your own.” —Michele Curtis, MD.Being transferred? Speak up. “If you go to a smaller hospital and it has to transfer you to a different medical center, demand that it ship you to the closest one that can handle your care. What’s happening is that community medical centers are sending patients instead to the big hospital that they’re affiliated with, even if it’s farther away. It happens even when a patient is bleeding to death or having a heart attack that needs emergency care.” —Evan Levine, MD.“Don’t assume the food is what you should be eating. There’s no communication between dietary and pharmacy, and that can be a problem when you’re on certain meds. I’ve had patients on drugs for hypertension or heart failure (which raises potassium levels), and the hospital is delivering (potassium-rich) bananas and orange juice. Then their potassium goes sky high, and I have to stop the meds. Ask your doctor whether there are foods you should avoid.” —Evan Levine, MD.On weekends and holidays, hospitals typically have lighter staffing and less experienced doctors and nurses. Some lab tests and other diagnostic services may be unavailable. If you’re having a major elective surgery, try to schedule it for early in the week so you won’t be in the hospital over the weekend. —Roy Benaroch, MD, a pediatrician and the author of A Guide to Getting the Best Healthcare for Your Child.“Many hospitals say no drinking or eating after midnight the day before your surgery because it’s more convenient for them. But that means patients may show up uncomfortable, dehydrated, and starving, especially for afternoon surgery. The latest American Society of Anesthesiologists guidelines are more nuanced: no fried or fatty foods for eight hours before your surgery and no food at all for six hours. Clear liquids, including water, fruit juices without pulp, soda, Gatorade, and black coffee, may be consumed up to two hours beforehand.” —Cynthia Wong, MD, an anesthesiologist at University of Iowa Healthcare“Get copies of your labs, tests, and scans before you leave the hospital, along with your discharge summary and operative report if you had surgery. It can be shockingly difficult for me to get copies of those things. Even though I have a computer and the hospital has a computer, our computers don’t talk to each other.” —Roy Benaroch, MD.“One time, I ran into a patient I had performed a simple appendectomy on. He thanked me for saving his life, then told me it almost ruined him because he couldn’t pay the bill. Four hours in the hospital, and they charged him $12,000, and that didn’t even include my fee. I showed his bill to some other doctors. We took out an ad in the newspaper demanding change.” —Hans Rechsteiner, MD, a general surgeon in northern Wisconsin.We're Impatient. Your doctor generally knows more than a website. I have patients with whom I spend enormous amounts of time, explaining things and coming up with a treatment strategy. Then I get e-mails a few days later, saying they were looking at this website that says something completely different and wacky, and they want to do that. To which I want to say (but I don't), "So why don't you get the website to take over your care?"--James Dillard, MDNinety-four percent of doctors take gifts from drug companies, even though research has shown that these gifts bias our clinical decision making. Internist, Rochester, Minnesota Those so-called free medication samples of the newest and most expensive drugs may not be the best or safest.--Internist, PhiladelphiaDoctors get paid each time they visit their patients in the hospital, so if you're there for seven days rather than five, they can bill for seven visits. The hospital often gets paid only for the diagnosis code, whether you're in there for two days or ten. Evan S. Levine, MDWhen a parent asks me what the cause of her child's fever could be, I just say it's probably a virus. If I told the truth and ran through the long list of all the other possible causes, including cancer, you'd never stop crying. It's just too overwhelming. Pediatrician, Hartsdale, New York60% of doctors don't follow hand-washing guidelines. Source: CDC Morbidity and Mortality Weekly Report96% of doctors agree they should report impaired or incompetent colleagues or those who make serious mistakes, but ...94% of doctors have accepted some kind of freebie from a drug company.Source: New England Journal of Medicine58% doctors would give adolescents contraceptives without parental consent. Source: New England Journal of MedicineYour doctor or nurse may have messed up your meds.Doctors in training look the same as doctors in charge.Your medical records are not confidential. If your charts are an open book, it boosts the odds that sensitive details about your health will slip into the hands of people who could use them against you—employers, ex-spouses, or medical identity thieves, says Deborah Peel, M.D., founder and chairwoman of the nonprofit advocacy group Patient Privacy Rights.Your doctor's hands may be filthy.Toronto doctor reveals secrets of hospital slang. Obese patients are “whales” or “beemers”. Old people are known as FTDs, or “failure to die”ER doctors want you to know ER is just like a horror movie. At first you're excited for every day, then there's lots of blood and screaming and crying and it's terrifying. And there's plenty of riddles, like, 'What exactly did you shove up there?!'" It takes an entire team to make an ER run. They work around the clock with little to no breaks. They care about you and they will fight for you.These are some secrets regarded to doctors including surgeons. They are also human beings and make mistakes. We need to collaborate with them to get the best results for your care. Understand them more.Thanks for reading.Sources:50 Secrets Hospitals Don’t Want to Tell You (But Every Patient Should Know)41 secrets your doctor would never share with you8 Secrets Your Hospital Keeps23 Things ER Employees Want You To KnowToronto doctor reveals secrets of hospital slang