Discharge summary

Published

Hi!!

New to HH and I am doing my first discharge. I did not do the SOC and was given this patient on her second recert. I was only able to see her twice and now I have to discharge her. OASIS not a problem, but can anyone provide a short/simple sample of what to write in the summary? THANKS!!!

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Specializes in Pedi.

What did you do for the patient/why were you following her? I don't think any of us can tell you what to write when we don't know this patient.

If I am discharging a patient- let's say the patient is a 10 year old with ALL who has completed treatment and is being discharged from services after 2 years, I would write:

"Patient followed for oncology teaching, home labs and chemotherapy administration throughout the duration of his treatment. All treatment completed 4/1/14, PAC removed 4/14/14, patient has no further home nursing needs and will follow-up in clinic."

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Specializes in NICU, PICU, Transport, L&D, Hospice.

The basic rule of thumb is to address each problem in the POC and discuss how the goals of care were met thereby justifying discharge.

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