Who needs a Hospital Discharge Summary Form?
A Hospital Discharge Summary is a mandatory form to be filled out by a physician or a medical specialist who has been treating a patient whose hospital stay lasted longer than 48 hours. Such a form filled out on each patient who is expecting being released from or transferred to another hospital, a rehabilitation facility or other type of inpatient treatment institutions.
The attending doctor is in charge of the summary being filled out correctly and promptly.
What is the Hospital Discharge Summary Form for?
A Hospital Discharge Summary is a report overviewing a patient’s hospitalization from admission until discharge. Depending on the patient’s condition and treatment, it may be short or particularized. Regardless of its scope, the summary is the primary document stating the patient’s diagnosis, provided the treatment plan, and procedures performed.
Is the Hospital Discharge Summary Form accompanied by other forms?
The Hospital Discharge Summary is one of the documents included on a patient’s medical record. The latter has the following essential parts:
- Face Sheet (with all the basic information on the patient)
- Hospital Discharge Summary
- Transfer Forms
- Emergency Department Records
- Treatment Orders
- History and Physical
- Progress Notes
- Nurses’ Documentation
- Operative Reports
- Miscellaneous forms
When is Hospital Discharge Summary Form due?
As a rule, the Hospital Discharge Summary must be filed no longer than 30 days after the patient’s discharge. However, it can be correlated towards a shorter period according to the hospital’s bylaws.
How do I fill out Hospital Discharge Summary Form?
Typically, the attending physician will dictate the information to include on the form to the junior medical professional (for instance, an intern). The completed Summary must cover the following issues:
- medical institution’s information
- date and reason for hospitalization
- initial diagnosis
- current condition
- discharge plan and follow-up care
- attending doctor’s signature, etc.
Where do I send Hospital Discharge Summary Form?
One copy of the Summary will be directed to the patient’s GP, one more will be kept as a part of the patient’s medical record, and the other copy will be given to the patient for their needs.