The discharge summary needs to include specific information regarding the patient; list seven areas that are necessary.
What will be an ideal response?
The discharge summary is a vital piece of information in the patient chart as it summarizes the patient's stay and includes the reason for hospitalization; the final diagnoses, including the principal diagnosis, any comorbidities, and/or complications; significant findings from tests or procedures; procedures performed; response to treatment; condition on discharge; and the discharge instructions including medications, physical activity limitations, diet, and follow-up care.
Health Professions