Discharge Summary – Reflections and Proposal for a Practical Guide
DOI:
https://doi.org/10.24950/rspmi.2704Keywords:
patient discharge summary; transitional care; problem-oriented medical recordsAbstract
A discharge summary is a clinical report relative to an episode of hospitalization. Its role is to ensure the transition of care between healthcare teams. Writing a discharge summary is a structured exercise of synthesizing relevant information, explaining the reasoning behind decisions and communicating the healthcare plan. A discharge summary is an opportunity to look at the patient´s situation as a whole and to update the priorities of their individual care plan. The Government determined a set of minimum mandatory information to normalize discharge summaries. This instrument is useful, but it does not replace the clinical report itself, which is a highly personalized document, impossible to parameterize. To ensure that a free field text is not structurally fragile, it is necessary to adopt a recording system that allows dealing with complex systems, such as problem-oriented medical records. In practical terms, a guide for writing problem-oriented discharge notes is proposed.
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