Medical Documentation

and Interviewing

Discharge Summary
Typically Dictated
Be sure to identify yourself
spell your name (D-A-W-N)
indicate your title (PA-C, PAS)
for whom you are dictating (attending name)
• Include PA preceptor’s name for whom you are
dictating
Identify the patient (Joseph Java, ID#)
ID/MRN (institution directed)
Points to Cover in PPT
1. DC Summary Content
2. Format
3. Exceptions to need of DC summary
4. Transfer Summary
5. Completed Medical Records
1. DC Summary Content
Reason for Hospitalization
Significant findings
Procedures performed and treatments
rendered
Patient’s condition at discharge
Instructions to patient and family
Pt. Name: Java, Joseph
Pt. ID: 999-99-999
D/S Prepared on: 07/30/17
Allergies: NKDA
DISCHARGE SUMMARY
Admission Date:
07/29/17

Admission Diagnosis:

•Acute Myocardial Infarction

•Hyponatremia [Low sodium]
•Anemia
Format
Admission Date Procedures/diagnostics
Admission Diagnosis (with dates)
Discharge Date Consults
Discharge Diagnosis Brief HPI
Attending and Service PE (pertinent)
caring for pt
Labs (pertinent)
Referring Physician
(and address if
available)
Format
Hospital course
summarizes the evaluation and treatment and progress
of patient
Condition at discharge
improved
unchanged
Disposition
Where pt was sent
• home
• another hospital/SNF/NH
Format
Discharge Medications
med name, dose, route, # given and no. of
refills
Discharge Plans
RTC, diet etc.
Exceptions to DC Summary rule
Progress note may be substituted for DC Summary
Normal newborn discharge from uncomplicated
delivery
Patients hospitalized for less than 48 hr
May be handwritten
condition at discharge
discharge instructions
follow up care required
Transfer Summary
Transferred from one level of care to
another in the same organization but
different caregiver
e.g. Hospital to NHU
• reason for transfer
• condition of pt
If same caregiver, progress note may suffice
The Officially Completed
Medical Record
Per accreditation manual:
when contents reflect patient’s condition on arrival,
diagnosis, test results, therapy, condition and in hospital
progress, and condition at discharge
when contents including final progress notes are
assembled and authenticated
when final diagnoses and complications are recorded
without use of symbols or abbreviations
Accreditation: Complete Reports
If average of total no. of records delinquent for
any reason equal to or exceeds 2x the average
monthly discharges, conditional accreditation
will be recommended
Discharge Summary Practice