Academic clinical discharge

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Academic clinical discharge summary notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating an evidence-based plans of care

Develop an academic clinical discharge summary note based on a hospital patient seen during clinical/practicum. The discharge summary note should include the following:

Reason for admission: Include the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis.
List of all procedures: Include all dates, significant findings, and any anesthetics and contrast used during procedures.
Complete list of consults during hospitalization: Include any providers or services consulted during the stay.
Patient’s condition at discharge: Include a physical exam prior to discharge that documents that patient is stable at discharge and has safe disposition and transportation. What diagnostic criteria confirmed the discharge diagnosis?
Complete list of discharge medications: Full list with all dosages, frequencies, and quantity of medications prescribed or dispensed.
Pending test results for follow up: Complete list of any pathology, cultures, radiology, or other diagnostic tests still pending, and who is responsible for follow-up on the final results.
Complete list of discharge instructions: Full list of directions regarding infection prevention, new medications, and returning to daily activities.
Complete list of discharge follow-ups: Full list of any therapies, treatments, referrals, consults, and follow-up appointments. What diagnostic criteria were needed after discharge?
Summary: What questions were raised during the hospital stay? Include all explanations and answers to these questions. What questions were raised that required further exploration? What kind of discharge planning did you need? Characterize your patient interaction activities.

Sample Solution

Academic Clinical Discharge Summary

Patient: John Doe Age: 65 years old Sex: Male Date of admission: 2023-09-28 Date of discharge: 2023-10-03

Reason for admission:

Mr. Doe was admitted to the hospital with a chief complaint of chest pain and shortness of breath. He had a history of coronary artery disease and had undergone a coronary artery bypass graft (CABG) 10 years ago. He also had a history of hypertension and diabetes.

List of all diagnoses in order of acuity:

  1. Acute myocardial infarction (AMI)
  2. Coronary artery disease (CAD)
  3. Hypertension
  4. Diabetes mellitus type 2
  5. Obesity

ICD-10 diagnosis:

I21.9 Unspecified acute myocardial infarction

List of all procedures:

  • 2023-09-28: Coronary angiography and stenting
  • 2023-09-30: Echocardiogram

Significant findings:

The coronary angiography showed a 90% stenosis of the left anterior descending artery (LAD). The patient underwent stenting of the LAD. The echocardiogram showed a left ventricular ejection fraction (LVEF) of 45%.

Anesthetics and contrast used during procedures:

  • Coronary angiography and stenting: Lidocaine, propofol, ketamine, and verapamil. Iodinated contrast was used.
  • Echocardiogram: None.

Complete list of consults during hospitalization:

  • Cardiology
  • Endocrinology
  • Nutrition

Patient’s condition at discharge:

Mr. Doe’s vital signs were stable at discharge. His physical exam was unremarkable. His LVEF had improved to 50%.

Diagnostic criteria confirmed the discharge diagnosis:

The diagnosis of AMI was confirmed by the patient’s clinical presentation, electrocardiogram findings, and coronary angiography findings.

Complete list of discharge medications:

  • Aspirin 81 mg once daily
  • Clopidogrel 75 mg once daily
  • Lisinopril 10 mg once daily
  • Metformin 500 mg twice daily
  • Insulin glargine 30 units at bedtime
  • Rosuvastatin 20 mg once daily

Pending test results for follow up:

None.

Complete list of discharge instructions:

  • Take all medications as prescribed.
  • Follow up with your cardiologist in 1 week.
  • Eat a healthy diet and exercise regularly.
  • Avoid smoking.

Complete list of discharge follow-ups:

  • Cardiology appointment in 1 week
  • Nutrition counseling in 2 weeks

What diagnostic criteria were needed after discharge?

The patient was discharged with a diagnosis of AMI. No further diagnostic criteria were needed after discharge.

Summary:

Mr. Doe was admitted to the hospital with a chief complaint of chest pain and shortness of breath. He was diagnosed with an AMI and underwent coronary angiography and stenting. His condition improved during hospitalization, and he was discharged with stable vital signs and a normal physical exam. He was prescribed aspirin, clopidogrel, lisinopril, metformin, insulin glargine, and rosuvastatin. He was instructed to follow up with his cardiologist in 1 week and nutrition counseling in 2 weeks.

Questions raised during the hospital stay:

  • What caused the AMI?
  • Is there anything more that can be done to prevent future AMIs?
  • How can I manage my chronic conditions?

Explanations and answers to these questions:

  • The AMI was likely caused by a rupture of a plaque in the LAD.
  • There are a number of things that can be done to prevent future AMIs, including taking medications as prescribed, eating a healthy diet, exercising regularly, and avoiding smoking.
  • The patient’s chronic conditions can be managed by taking medications as prescribed, following a healthy diet, and exercising regularly.

Questions raised that required further exploration:

  • What is the patient’s level of understanding of his condition and medications?
  • What are the patient’s psychosocial support resources?
  • What are the patient’s barriers to adhering to his treatment plan?

Kind of discharge planning needed:

  • Education about AMI, coronary artery disease, hypertension, diabetes, and the patient’s new medications
  • Referral to nutrition counseling
  • Follow-up appointments with cardiology and primary care physician

Characterization of patient interaction activities:

The patient was

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