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.
Overall assessment: Identify health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes.2

Sample Solution

Academic Clinical Discharge Summary Note

Patient: John Doe Age: 65 Sex: Male Date of Admission: 08/25/2023 Date of Discharge: 08/31/2023

Reason for Admission:

Mr. Doe was admitted to the hospital with a chief complaint of chest pain. He reported having a substernal, crushing chest pain that radiated to his left arm and jaw. The pain began at rest and was exacerbated by exertion. He also reported having shortness of breath and diaphoresis.

Past Medical History:

  • Hypertension
  • Hyperlipidemia
  • Diabetes mellitus type 2
  • Coronary artery disease

Social History:

  • Married
  • Two children
  • Retired teacher
  • Smoker for 40 years, quit 10 years ago

Medications:

  • Metoprolol 50mg twice daily
  • Lisinopril 20mg daily
  • Atorvastatin 20mg daily
  • Metformin 1000mg twice daily

Physical Examination:

On admission, Mr. Doe was in moderate distress due to chest pain. His vital signs were as follows:

  • Temperature: 98.6°F
  • Heart rate: 100 beats/minute
  • Respiratory rate: 24 breaths/minute
  • Blood pressure: 180/100 mmHg

His lungs were clear to auscultation and his heart rate was regular without murmurs. He had no tenderness or distention of his abdomen.

Laboratory Findings:

  • Electrocardiogram: Sinus tachycardia with ST segment elevations in leads V1-V4
  • Troponin: Elevated
  • Creatinine kinase-MB: Elevated

Imaging Findings:

  • Chest X-ray: Normal
  • Echocardiogram: Left ventricular ejection fraction of 50% with regional wall motion abnormalities in the anterior wall

Diagnosis:

  • Acute myocardial infarction (STEMI)

List of All Procedures:

  • Cardiac catheterization with stent placement to the left anterior descending artery

Complete List of Consults During Hospitalization:

  • Cardiology
  • Cardiothoracic surgery
  • Pulmonary medicine

Patient’s Condition at Discharge:

Mr. Doe is stable at discharge. His vital signs are within normal limits and his chest pain has resolved. He has been instructed to follow up with his cardiologist in one week.

Complete List of Discharge Medications:

  • Aspirin 81mg daily
  • Clopidogrel 75mg daily
  • Lisinopril 40mg daily
  • Atorvastatin 40mg daily
  • Metoprolol 100mg twice daily

Pending Test Results for Follow Up:

  • None

Complete List of Discharge Instructions:

  • Take all medications as prescribed.
  • Follow up with cardiologist in one week.
  • Avoid strenuous activity for the next two weeks.
  • Eat a healthy diet and exercise regularly.

Complete List of Discharge Follow-Ups:

  • Cardiologist follow-up in one week

Diagnostics Criteria Confirmed the Discharge Diagnosis:

  • Elevated troponin and creatine kinase-MB levels
  • ST segment elevations on electrocardiogram
  • Regional wall motion abnormalities on echocardiogram

Summary:

Mr. Doe was admitted to the hospital with a diagnosis of acute myocardial infarction (STEMI). He underwent cardiac catheterization with stent placement to the left anterior descending artery. He is stable at discharge and has been instructed to follow up with his cardiologist in one week.

Questions Raised During the Hospital Stay:

  • What is Mr. Doe’s risk of recurrent myocardial infarction?
  • What medications should Mr. Doe take to prevent recurrent myocardial infarction and other cardiovascular events?
  • What lifestyle changes should Mr. Doe make to reduce his risk of cardiovascular disease?

Explanations and Answers to Questions:

  • Mr. Doe’s risk of recurrent myocardial infarction is moderate. He has several risk factors for cardiovascular disease, including hypertension, hyperlipidemia, and diabetes mellitus type 2. He also has a history of smoking.
  • Mr. Doe should take aspirin, clopidogrel, lisinopril, atorvastatin, and metoprolol to prevent recurrent myocardial infarction and other cardiovascular events.
  • Mr. Doe should make lifestyle changes to reduce his risk of cardiovascular disease, such as eating a healthy diet, exercising regularly, and quitting smoking.

Questions Raised That Required Further Exploration:

  • What is the underlying cause of Mr. Doe’s coronary artery disease?
  • Does Mr. Doe have any other cardiovascular risk factors, such as peripheral artery disease or carotid artery stenosis?
  • Is Mr. Doe eligible for any other preventive therapies

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