Discharge Summary format

[Guest guest]

Hi all!

There is a debate going on about verb tense in the different sections (headings)

of a Discharge Summaries. For example, the History of Present Illness versus

the Physical Examination sections. I cannot find an actual reference in AAMT

Bos or Do's and Dont's where they state specifically about verb tense in a

Discharge Summary. I do find examples of Discharge Summaries in both books and

they conflict in one area of the Discharge Summary - that area being the History

of Present Illness.

What I would like to know from all of you is what you are actually doing with

Discharge Summaries. Do you follow a particular rule when it comes to verb

tense in the Discharge Summary? Do you go by AAMT Bos, Do's and Don't or just

transcribe them like the doctor dictates them and not bother to worry about it?

What do you " by the book " folks do with a Discharge Summary - what are the rules

are you understand and apply them? For the students, what are they teaching you

about Discharge Summaries regarding verb tense?

I learned that the History of Present Illness was in present tense regardless of

the fact that it is a Discharge Summary and that everything else in the

Discharge Summary is in past tense, which is what AAMT Bos appears to suggest.

I'd love to get a discussion going about this so I can have a relatively hard

and fast rule about it. Thanks much, Teri

[Guest guest]

I've never heard of any hard, fast rule about particular sections of

particular reports. It's just been about what the doc is dictating and what

the context of the sentence is. If the doc is dictating in the HPI, he can

use a mixture of past and present tense depending on what the situation is.

He could say:

One month ago, the patient began to have (obvious past progressive tense

that can't be changed) fever, chills with occasional night sweats. She also

complained (PAST TENSE) of left-sided pleuritic pain for the past two weeks.

She also relates (present tense) to a 30-pound weight loss in the last

three months attributed to a poor appetite.

Are you talking about, for example, changing the past tense that was

dictated above to " ...also complains of left-sided... " since it's in the HPI

and it's something she is still experiencing?

I was taught to just transcribe what the doc dictates myself. Anyone else?

----Original Message Follows----

To: " NMTC " <nmtc >

Subject: Discharge Summary format

Date: Wed, 16 Jan 2002 10:16:55 -0800

Hi all!

There is a debate going on about verb tense in the different sections

(headings) of a Discharge Summaries. For example, the History of Present

Illness versus the Physical Examination sections. I cannot find an actual

reference in AAMT Bos or Do's and Dont's where they state specifically about

verb tense in a Discharge Summary. I do find examples of Discharge

Summaries in both books and they conflict in one area of the Discharge

Summary - that area being the History of Present Illness.

What I would like to know from all of you is what you are actually doing

with Discharge Summaries. Do you follow a particular rule when it comes to

verb tense in the Discharge Summary? Do you go by AAMT Bos, Do's and Don't

or just transcribe them like the doctor dictates them and not bother to

worry about it? What do you " by the book " folks do with a Discharge Summary

- what are the rules are you understand and apply them? For the students,

what are they teaching you about Discharge Summaries regarding verb tense?

I learned that the History of Present Illness was in present tense

regardless of the fact that it is a Discharge Summary and that everything

else in the Discharge Summary is in past tense, which is what AAMT Bos

appears to suggest.

I'd love to get a discussion going about this so I can have a relatively

hard and fast rule about it. Thanks much, Teri