To comply with The Joint Commission requirements, you must document your assessment of a patient's continuing care needs plus any referrals for care and begin discharge planning early in the patient's stay. Discharge summaries reflect the reassessment and evaluation of your nursing care. They're commonly combined with patient discharge instruction forms and provide useful data about additional teaching needs and the patient's ability to care for herself.
To help with this documentation, many facilities combine discharge summaries and patient instructions in one form. This form contains sections for recording patient assessment, patient education, detailed special instructions, and the circumstances of discharge. It uses a narrative style along with open- and closed-ended questions (see A perfect combination). A combined discharge summary form provides useful data about additional teaching needs and points out whether the patient has the information she needs to care for herself or to get further help. The form establishes compliance with The Joint Commission requirements and helps safeguard you from malpractice accusations.
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Not all facilities use combined forms-some use narrative discharge notes (see Parting words). If your facility uses these notes, be sure to include the following information on the form:
* the patient's status at admission and discharge
* significant information about the patient's stay in the facility, including resolved and unresolved patient problems and referrals for continuing care (for example, when the patient should see her health care provider for follow-up after discharge)
* instructions given to the patient, her family members, and other caregivers about medications, treatments, activity, diet, referrals, follow-up appointments, and other special instructions.
After completing your patient's discharge summary form, give one copy to the patient and put another copy in the medical record for future reference. Make sure that the completed form outlines the patient's care, provides useful information for further teaching and evaluation, and documents that the patient has the information she needs to care for herself or to get further help.
|Table. A perfect combination By combining a patient's discharge summary with instructions for care after discharge, you can fulfill two requirements with a single form. When using this documentation method, be sure to give one copy to the patient and keep one for the medical record.|
Charting Made Incredibly Easy!!, 3rd edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2005.
Complete Guide to Documentation, 2nd edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2007.