discharge summary
discharge summary
A document prepared by the attending physician of a hospitalized Pt that summarizes the admitting diagnosis, diagnostic procedures performed, therapy received while hospitalized, clinical course during hospitalization, prognosis, and plan of action upon the Pt's discharge with stated time to followupdischarge summary
Patient care
It is prepared when the patient is released from a health care facility and incorporated in her permanent medical records. It should ideally include the explanation for the patient's admission; a record of her complaints, physical findings, laboratory results and radiographic studies while hospitalized; a list of changes in her medications at discharge; and recommendations for follow up care. For optimal patient care it should be transmitted to or reviewed with her outpatient primary care provider.