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. Reason for admission: Include the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis.
2. List of all procedures: Include all dates, significant findings, and any anesthetics and contrast used during procedures.
3. Complete list of consults during hospitalization: Include any providers or services consulted during stay.
4. 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?
5. Complete list of discharge medications: Full list with all dosages, frequencies, and quantity of medications prescribed or dispensed.
6. 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 final results.
7. Complete list of discharge instructions: Full list of directions regarding infection prevention, new medications, and returning to daily activities.
8. 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?
9. 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.
10. Overall assessment: 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).
Don’t Forget to include all coding including ICD-10, CPT and all others.
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.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
|Course Code||Class Code||Assignment Title||Total Points|
|ANP-650||ANP-650-XO0103XB||Academic Clinical Discharge Summary Note||65.0|
|Reason for Admission and Full Diagnosis||10.0%||A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are extremely thorough and include substantial supporting details.|
|All Procedures||10.0%||A list of all dates, significant findings, any anesthetics, and contrast used during procedures is present.|
|Consults During Hospitalization||10.0%||A complete list of consults during hospitalization, including any providers or services consulted during stay is present.|
|Condition of Patient at Discharge||10.0%||A physical exam prior to discharge that documents patient is stable at discharge and has safe disposition and transportation is present.|
|Discharge Medications||10.0%||A full list with all dosages, frequencies, and quantities of medications prescribed or dispensed is present.|
|Tests for Follow-Up||10.0%||A complete list of any pathology, cultures, radiology, or other diagnostic tests still pending and who is responsible for follow-up on final results is present.|
|Listing of Discharge Follow-Ups||10.0%||A complete list of discharge therapies, treatments, referrals, consults, and follow-up appointments is present.|
|Organization and Effectiveness||20.0%|
|Mechanics of Writing (includes spelling, punctuation, grammar, language use)||20.0%||Writer is clearly in command of standard, written, academic English.|
|Paper Format (Use of appropriate style for the major and assignment)||5.0%||All format elements are correct.|
|Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)||5.0%||Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.|
Running head: CLINICAL DISCHARGE SUMMARY NOTE 1
CLINICAL DISCHARGE SUMMARY NOTE
Clinical Discharge Summary Note
Reason for admission:
Patient is a 75-year-old male diagnosed with duodenal mass, neuroendocrine carcinoma, poorly differentiated in November 2018 that was repaired by completing a whipple surgical procedure on September 2019. The patient arrival from home via personal automotive to the Moffitt Cancer alert and oriented, vital sign with in normal limit, stable appearance, and with wife by his side. “A Whipple procedure is a type of surgery used to treat pancreatic cancer when the tumor is located in the head of the pancreas. Unlike a “classic” Whipple procedure in which the lower part of the stomach, all of the duodenum and the head, neck and uncinated process of the pancreas are removed, this modified resection preserves the entire stomach, the pylorus and several centimeters of the upper duodenum (Gastroenterology Week., 2007)”. This patient past surgical history revealed s/p cystoscopy and resection in 1995; s/p partial left nephrectomy in 2016; s/p antrectomy and reconstruction 30 years ago; bilateral cataracts; and left leg stent times two 9 year ago.
1. Malignant neoplasm of pancreas, unspecified- C25.9.
2. Type 2 Diabetes w/ diabetic peripheral angiopathy w/o gangrene- E11.51.
3. Chronic obstructive pulmonary disease- J44.9.
4. Gastrostomy status- Z93.1.
5. Peripheral vascular angioplasty status w/ implants and grafts –Z95.820.
6. Personal history of nicotine dependence- “Z87.891 (www.icdcodelookup.com. 2019)”.
List of all procedures:
1. Epidural, infusion of bupivavaine 0.625%
2. Exploratory laparotomy
3. Pancreaticoduodenectomy (whipple).
4. Gastrostomy or jejunostomy +/- vein resection/reconstruction.
Complete list of consults during hospitalization:
1. DM Educator consulted for discharge home medication regiment
2. PT/OT consulted
3. Dietitian consulted for GI soft/ high protein diet
4. Consulted acute post-surgical pain team
5. 2unit of PRBC given for HGB 7.6
6. Home health ordered for walker
Patient’s condition at discharge:
“Pancreaticoduodenectomy is a complex surgical procedure associated with high morbidity and prolonged length of stay. Enhanced recovery after surgery principles have reduced complications rate and length of stay for multiple types of operations (Daniel, S. K., 2018)”. This patient hospital course progressed as expected. Postoperatively, pain was controlled by multimodal therapy and transitioned to by mouth medications prior to discharge. Both NGT removed and the patient tolerating diet with return of bowel function. UOP satisfactory. Surgical drain removed without incident after acceptable output noted times two. Jackson Pratt drainage was negative times two prior to d/c. PICO dressing removed without incident. PT/OT consulted. Ambulated well with assistance and able to perform ADLs with assistance. Home health is ordered for walker, PT/OT. Labs and VS stable at discharge. Patient is appropriate for discharge home.
Complete list of discharge medications:
1. Aspirin 81mg, 1 tablet daily
2. Lovenox prophylactically
3. Creon 36,000 unit, 1 capsule, 3 times a day
4. Hydromorphone 8MG, 1 to 2 tablet as needed
5. Metoprolol 25mg, 1 tablet, 2 times a day
6. Lidocaine prilocaine topical 2.5%, 1 application daily
7. Metformin 500mg, 1 table, 2 times daily
8. Multivitamin oral, 1 tablet daily
9. Ondansetron 8mg, 1 tablet, PRN
10. Pantoprazole 40mg, 1 tablet daily
11. Polyethylene glycol 3350 oral 17mg, oral powder daily
Pending test results for follow up
Patient will return to clinic on Monday and at that time lab draw for CBC, CMP, magnesium, phosphate will be drawn and evaluated due to previous lab draw revealed a low RBC, H/H, platelet count, sodium, potassium, chloride, calcium, total protein, and albumin level.
Complete list of discharge follow-ups:
1. Follow up with PCP on Friday/ Monday for hypertension
2. Plavix with be started after follow up appointment
3. Follow up with GI clinic on Friday/ Monday status post discharge
4. Home health skilled nursing service on Monday (wound care)
5. DM Educator appointment on Monday
Daniel, S. K., ⨯ Lucas, W. T., Mann, G. N., Park, J. O., & Pillarisetty, V. G. (2018). Standardization of perioperative care facilitates safe discharge by postoperative day five after pancreaticoduodenectomy. PLoS One, 13(12) doi:http://dx.doi.org.lopes.idm.oclc.org/10.1371/journal.pone.0209608
Pancreatic cancer; whipple webcast highlights innovative surgical treatment for pancreatic cancer. (2007, Sep 10). Gastroenterology Week Retrieved from https://lopes.idm.oclc.org/login?url=https://search-proquest-com.lopes.idm.oclc.org/docview/237340908?accountid=7374
10 Code Lookup. (2019). Retrieved from https://icdcodelookup.com/icd-10/codes/malignant neoplasm of pancreas.