Guest guest Posted May 14, 1999 Report Share Posted May 14, 1999 We write D/C sumaries on all cases. The acute care volume is a challenge. We " catch " many in medical records. Allan B. Trumbull, Director P.T. Mount Clemens General Hospital Mt. Clemens, MI 48043 atrumbul@... Discharge Summaries What policies do acute settings have in place as it relateses to discharge summaries. Specifically, do you require a D/C note on patients seen briefly (i.e. 2 days) or weekend discharges (MR chart is gone when therapists return on Monday). I would appreciate any insight from what other facilities are doing. (Can you tell JCAHO is coming) T ^^^^^^^^^^^^^^^^ Todd Cepica, P.T. Director of Physical Medicine and Rehabilitation University Medical Center Lubbock, Tx 79417 Ph: Fax: ntc@... ------------------------------------------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 14, 1999 Report Share Posted May 14, 1999 Todd, I believe it is part of the APTA guidelines to do a DC eval on any pt treated by a PT. In acute care, it is a challenge yes, but nevertheless, a DC eval should still be completed including status at DC, meeting of goals, DC recommendations, need for continued services, etc... Some patients can be a combined Eval, Rx, and DC all in one such as a simple crutch fitting and training of an acute pt. We write a DC note on a blank progress sheet and send it to Med Rec if the pt was DC'd before we could get to the chart. Hope this helps. Romano PT ------------------------------------------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 18, 1999 Report Share Posted May 18, 1999 Attached is a sample " down and dirty " version that takes just a few minutes to complete. Form is in Adobe Format Angie ,PT Images At 07:17 AM 5/18/99 -0400, you wrote: >We do require a discharge summary on all patients in our acute care setting. >We try to refer back to initial evals or flowsheets for objective >information on patients who were seen briefly but require full assessments >at time of d/c. > > >> Discharge Summaries >> >> What policies do acute settings have in place as it relateses to discharge >> summaries. Specifically, do you require a D/C note on patients seen >> briefly (i.e. 2 days) or weekend discharges (MR chart is gone when >> therapists return on Monday). I would appreciate any insight from what >> other facilities are doing. (Can you tell JCAHO is coming) >> T >> >> ^^^^^^^^^^^^^^^^ >> Todd Cepica, P.T. >> Director of Physical Medicine and Rehabilitation >> University Medical Center >> Lubbock, Tx 79417 >> Ph: Fax: >> ntc@... >> >> >> >> ------------------------------------------------------------------------ >> Quote Link to comment Share on other sites More sharing options...
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