I'm on my first acute care clinical in Texas and the hospital I am working at is looking for the most efficient way to stay in compliance with the documentation of discharge summaries for all patients. I am at a pretty good size hospital (500+ beds) and our patient turnover is rather quick. Patients are always "falling off the list," getting discharged by the doctors, changing medical status, etc. We use EPIC for all documentation and it seems like it would be extremely tedious to have to look up every patient that was discharged by the doctors the day before and write a separate PT d/c summary on them. The easy cases are the ones that are evaluated and discharged from PT rather quickly because they have either met their goals or PT is not indicated at the time. I am wondering how you document discharge summaries effectively and efficiently in your acute care experience. Thanks for all the help!
Discharge Summaries in Acute Care
- Thread starter KB1713
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During my acute rotation, the secretary somehow had a list of people who were discharged from the hospital and "slipped" through... I don't know how she got this list if it was from a program, or what, but we would use that to determine who had been discharged without a PT d/c summary. Then, we would simply go in and write something to the affect of "Pt was discharged from X Hospital on Date. Please see last PT progress note. D/C patient from PT."
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On Epic Can't you just click the discharge button on the front page of the patient? And really you just need the secretary(or you) to look at the recently discharged(last 24 hours) if you notice the person not on your list. But yeah a basic "DC from PT secondary to hospital DC by MD" note takes care of it.
