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Medical Transcription: Discharge Summary

Each time a patient is released from a hospital, rehabilitation facility, or other in-patient care setting, a Discharge Summary is generated. The medical transcriptionist must be familiar with this type of report.

Overview

A Discharge Summary provides an overview of a patient’s hospitalization from admission through discharge. It can be a few brief paragraphs or a multipage report, depending on the complexity of the patient’s condition and treatment. A typical report covers the following topics:

  • Admission and discharge dates

  • Names of physicians involved in the patient’s care

  • Initial and final diagnoses

  • Key laboratory and diagnostic data

  • A list of operations and medical procedures performed

  • A chronological narrative of the patient’s progress from admission through discharge

  • Medications the patient is on at the time of discharge

  • The patient’s condition when discharged

  • Post-discharge instructions and plans

The layout, format, and sections included in a Discharge Summary vary between facilities and sometimes even among dictators at the same facility. The majority of the examples in this chapter comply with heading and layout styles recommended in The Book of Style for Medical Transcription, 3rd Edition, by AHDI.

A few stray from The Book of Style to demonstrate other common layouts you’re likely to encounter, such as a heading and data appearing on the same line rather than on separate lines. When transcribing, you should always format reports and headings as specified by the account you’re working on, regardless of what standards might otherwise apply.

The first thing a Discharge Summary does after stating the admission and discharge dates is name names. The patient’s primary care provider gets top billing, followed by specialists involved in the patient’s care.

Some transcription platforms will insert the names automatically, but others will require you to type some or all of it in. If it’s already present, confirm that it matches what’s dictated, because a finger slip somewhere along the way can result in a wrong patient or physician ID being entered into the system. A typical Discharge Summary heading will start out like this:

PATIENT NAME: Newman, Anita
ADMITTED: 00/00/0000
DISCHARGED: 00/00/0000
PRIMARY CARE PHYSICIAN: Kerry Oakey, MD
NUTRITIONAL CONSULTANT: Holden D’Mayo, MD

A dictator may supply a department name instead of a person’s name:

CONSULTANTS: Nephrology and Hematology.

Admitting and discharge diagnoses

A Discharge Summary may include both Admission and Discharge Diagnoses or just Discharge Diagnoses. They’re typically dictated in list form, usually near the beginning of the report. They should be formatted as a numbered list unless the facility specifies otherwise.

If a diagnosis is dictated using an abbreviation or acronym, it should be expanded to its full form and followed by the acronym in parentheses. So, “DVT” becomes “deep venous thrombosis (DVT).”

If the admitting and discharge diagnoses are identical, and the dictator may give them in one fell swoop as Admission and Discharge Diagnoses. You should transcribe them as separate lists anyway. The quick and easy way is to copy the admitting diagnoses list and change the title of the copy to Discharge Diagnoses.

Typical Admitting and Discharge Diagnoses lists look similar to this:

ADMISSION DIAGNOSES
1. Cerebrovascular accident (CVA) with left arm weakness.
2. Hyperlipidemia.
DISCHARGE DIAGNOSES
1. Cerebrovascular accident (CVA) with left arm weakness and MRI indicating subacute infarct involving the right posterior parietal lobe.
2. Hyperlipidemia.

Don’t be thrown for a loop if a dictator dictates primary and secondary diagnoses instead of admission and discharge diagnoses. When a patient has multiple coexisting conditions, the heading Primary Diagnosis is sometimes used to highlight the patient’s immediate problem; everything else is stashed under the heading Secondary Diagnoses.

History

The History section, also dictated as History of Present Illness or Brief History, provides introductory information about the patient and the circumstances leading up to admission to the facility. It’s often essentially a reiteration of the same section from the patient’s admitting History and Physical Examination (H&P) report, although perhaps worded differently. Given the degree of overlap, dictators sometimes just reference the H&P instead of repeating it.

BRIEF HISTORY
A 3-year-old boy with a history of asthma. On the night of admission he complained he was having trouble breathing, and his mother brought him to the ER. He was noted to have subcostal retractions, expiratory wheezes, and O2 saturation of 97% on room air. He was given albuterol nebulizer treatment and subsequently admitted to the pediatric floor.
HISTORY OF PRESENT ILLNESS
Please refer to admitting History and Physical Examination for full details of history and presentation.

Hospital course

The Hospital Course describes the patient’s progress and treatment between admission and discharge, in chronological order.

HOSPITAL COURSE
The patient underwent L5-S1 Gill decompressive laminectomy and posterior lumbar interbody fusion with pedicle screws with general anesthesia. She tolerated the procedure well. She did complain of some persisting numbness in the S1 dermatome of the right foot postoperatively. She was ambulatory, and her pain was under control with oral analgesics at the time of her discharge.

A patient’s History of Present Illness and Hospital Course are frequently combined under History and Hospital Course, Hospital Course, or Course in Hospital.

Laboratory data

The Laboratory Data section of a Discharge Summary includes only values directly relevant to the patient’s diagnosis and treatment, not every test that was administered. A dictator may emphasize this point by titling this section Pertinent Laboratory Data.

Diagnostic studies such as an MRI, CAT scan, and EKG often are dictated along with the lab results. However, if facility specifications permit it, it’s good practice to break them out into a separate section with an appropriate heading, like this:

LABORATORY DATA ON ADMISSION
BMP unremarkable. White blood cell count 8.1, hemoglobin 12.0, hematocrit 36.2, platelets 180,000. Urinalysis negative. Culture negative.
IMAGING
Principal imaging while in the hospital included CT of the head, which showed no evidence of acute intracranial hemorrhage.

Procedures performed

This section lists major procedures or operations performed during the patient’s hospitalization. It doesn’t include routine items such as starting an IV, only “big stuff” like an operation, insertion of a feeding tube, or another special procedure. Principal Procedures Performed and Operations Performed are common alternative titles for this section.

When there’s only one procedure, it will look like one of these (depending on how the facility prefers section headings to be formatted):

OPERATION PERFORMED
Right total knee replacement.
PROCEDURE PERFORMED: Right total knee replacement.

If there are multiple procedures, they should be listed vertically and numbered. As with other numbered lists, end each line with a period. If a procedure name is dictated using an acronym or abbreviation, expand it to its full form. For example, “LV angiogram” would become “left ventricular (LV) angiogram.”

A list of multiple procedures should look like this:

PROCEDURES PERFORMED
1. Left heart catheterization.
2. Coronary arteriogram.
3. Left ventricular (LV) angiogram.
4. Successful percutaneous transluminal coronary angioplasty (PTCA) of the mid left anterior descending (LAD) stenosis, reducing it to about 20% to 30%.

Physical examination on discharge

Most discharge summaries include a discharge physical examination. It usually pales in comparison to the formality and scope of an admitting physical, but it often includes similar headings. A discharge exam may be limited to the body systems immediately relevant to the patient’s diagnoses.

Frequently, the discharge exam is expressed in paragraph format, even if the admitting exam is customarily transcribed in a vertical format at the same facility. When in doubt, check previous reports from the facility to confirm the preferred layout.

PHYSICAL EXAMINATION
At the time of discharge vital signs were stable. HEENT: Pupils equal and reactive to light. Extraocular movements normal. Neck: No JVD or bruits. CVS: S1, S2 normal. Lungs: Clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended, with positive bowel sounds. Extremities: No pedal edema. Neurologic: Nonfocal. Skin: No rash. Surgical incision looks clean.

Discharge medications

Every discharge summary includes a list of medications the patient is taking at the time of discharge. It includes medications the patient was already taking on admission and incorporates modifications or additions. The items should be formatted as a numbered list with a period at the end of each line.

Plan/disposition

The final section of a Discharge Summary records the patient’s medical status at the time of discharge and whether he’s going home or somewhere else. If any follow-up appointments have been arranged, they may be listed here as well. The topics may be broken out into separate headings or dictated as a single paragraph, depending on the dictator’s habits and preference.

Discharge instructions

Dictators may break out instructions given to the patient or a caretaker at the time of discharge as a separate heading.

DISCHARGE INSTRUCTIONS
Maintain splint, clean, dry, and intact. Utilize ice to the left ankle as needed. Follow up with Dr. Finklefifer on Monday at 8:30 a.m.
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