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Discharge Summaries....Need advice

Posted

Specializes in ER, CCU, Geri.

F:283 Dischage Summaries: Recapitulation of the residents stay, Final Summary of Status.

Does anyone have any advice to share with me on the correct way these are to be done? How do you coordinate with medical records? Are these to be done after the entire chart is closed, or immediately after the resident is discharged. Does anyone have a form they could share with me? Thankyou to anyone who can offer assistance on this. :redbeathe

VivaLasViejas, ASN, RN

Specializes in LTC, assisted living, med-surg, psych. Has 20 years experience.

The facility where I work has a form for this, on which the discharging nurse documents a short summary of the resident's stay and a more detailed description of their physical condition and ADL status at the time of D/C (or death). The RCM and SW also write short blurbs in the progress notes ASAP after the resident leaves. The whole chart then goes to Medical Records.

CapeCodMermaid, RN

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience.

We were using a standard Briggs' 3 page referral. First page was insurance numbers and meds, second page nursing, and the 3rd page was shared between SS and rehab. Our medical director didn't like that form so I created a new one that fits the Massachusetts regulations and gives the information both the doc and the aftercare home agency needs. IM me your email and I'll send you the form if you want.

noc4senuf

Specializes in Geriatrics, WCC.

We have a short form that covers there stay and condition at discharge. This is filled out by one of my nurse managers and then the chart is sent to Med Rec.