If you’re looking for the “story” of how the patient entered the hospital and what happened while he/she was there, go to the Discharge Summary (Caution: This is different than the Discharge Instructions, which are essentially worthless unless you practice med-mal). The Discharge Summary is a synopsis of the major events in the time that the patient was in the hospital: It will include surgeries, procedures, complications (i.e. infections, organ failure, seizures) and anything else the doctor sees as an important event during the course of the treatment. It will usually be several pages long and will include the admission date and the discharge date at the top, and the discharge diagnoses at the end.
Many doctors will include a complete a review of systems, meaning they go through each bodily system (like the cardiac or neurological system) and discuss any abnormal findings and treatment given. What I recommend is to look at the narrative at the top of the page, which is the “story” of the patient’s care; after that, it just starts getting too technical for most laypersons.
Then skip to the bottom and look at the discharge diagnoses and the plan. The “discharge diagnoses” are the diagnoses that the patient is still suffering from and the “plan” gives the reader an idea of the status of the patient upon discharge: Did he/she go home or to a facility for further care and rehabilitation? This is important because it gives you an idea of how functional this patient will be and how long it will take for them to maximally recover. Obviously, someone that is discharged home is more likely to be functional with the activities of daily living (ADL’s = brushing teeth, bathing, cooking, etc) than someone that goes to a long-term rehabilitation center. Just because someone gets discharged to another facility doesn’t mean they won’t regain functionality in the ADL’s, it just means it might take a bit longer to get back to normal.
This month we are discussing Medical Record Review. The blog topics for this month are:
- Medical Records: Where to start (5/5/16)
- Medical Records: Emergency Records (5/12/16)
- Medical Records: Complications and Procedures (5/19/16)
- Medical Records: Abbreviations (5/26/16)
Note: To see all posts in this topic, click here