Academic Clinical Discharge Summary Note Academic clinical discharge summary notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, to develop and demonstrate critical thinking and clinical reasoning skills, and to practice identifying acute and chronic problems and formulating a evidence-based plans of care. Develop an academic clinical discharge summary note based on a hospital patient seen during clinical. The discharge summary note should include the following: ( Acute Care Hospital) 1. Include the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis. 2. Include all dates, significant findings, and any anesthetics and contrast used during procedures. 3. Include any providers or services consulted during stay. 4. Include a physical exam prior to discharge that documents that patient is stable at discharge and has safe disposition and transportation. diagnostic criteria confirmed the discharge diagnosis? 5. Full list with all dosages, frequencies, and quantity of medications prescribed or dispensed. 6. Complete list of any pathology, cultures, radiology, or other diagnostic tests still pending, and who is responsible for follow-up on final results. 7. Full list of directions regarding infection prevention, new medications, and returning to daily activities. 8. Full list of any therapies, treatments, referrals, consults, and follow-up appointments. diagnostic criteria were needed after discharge? 9. : questions were raised during the hospital stay? Include all explanations and answers to these questions. questions were raised that required further exploration? kind of discharge planning did you need? Characterize your patient interaction activities. 10. Identify health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes. Incorporate 3-5 peer-reviewed articles in the assessment or plan. (Minimum 1000 words). While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
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