Discharge summaries are notes generated
at the end of a hospital stay. They have some of the same
sections as history and physical notes but also have sections
that are unique to inpatient visits. There's actually mandated information
a discharge summary must contain. They must record the reason for the hospitalization, any
significant findings, all procedures and treatments provided, the patient's condition at discharge and any patient and family instructions. In practice, this information may be spread across many different
sections in the notes. Most notes contain
the admission diagnosis, the initial reason for the hospital stay. Sometimes this is recorded
as chief complaint. These notes also usually have
a history of present illness or HPI which is a longer description
of the reason for the admission, describing the different symptoms
a patient has had. Some notes also include
the discharge diagnosis. You may be wondering, "Why are there two different diagnoses?" In some cases, the patient is admitted
based on a suspected diagnosis. For example, if
the emergency room thinks they may have sepsis, a blood infection. However, as a patient is
cared for in the hospital, it may become clear that they don't have sepsis but instead have
a different condition. This second confirmed diagnosis is
listed as the discharge diagnosis. Because the scope of significant
findings has not been made clear, you may see a list of important
laboratory tests or radiology reports, physical exam findings and consultation
results in discharge summaries. Other traditional sections
like past medical history, family history and other similar
sections may also be included. Then most notes have a description
of the hospital course. That is a narrative description of all the procedures and treatments
performed during the hospital stay. The procedures completed may actually be broken out into its own section and, in some cases, the significant findings
repeated in this text summary. The patient's discharge
condition is typically recorded as the discharge disposition. There may also be a record
of discharge location.. Finally, as part of the patient
and family instructions, there is a list of
discharge instructions, discharge medications
or those medications the patient should continue to
take after their hospital stay, as well as any follow-up
appointments needed. As you can tell, these notes
can be very long and have very different organization
and header names based on each provider's
own personal style. However, these general types
of information will be available for
most discharge summaries.