Discharge Documentation Ojaghi Haghighi M D Why Discharge

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Discharge Documentation Ojaghi Haghighi M. D

Discharge Documentation Ojaghi Haghighi M. D

Why Discharge Note? �Medico-legal risk �Patient comprehension about the diagnosis & performed measures �Patient

Why Discharge Note? �Medico-legal risk �Patient comprehension about the diagnosis & performed measures �Patient adherence to medical advice �Proper follow up �Helping the next physician for effective treatment & continuity of care

Discharge Note Contents �Both verbally and in printed form (brightly colored papers) �Given diagnosis

Discharge Note Contents �Both verbally and in printed form (brightly colored papers) �Given diagnosis (or diagnoses) �What was done in the ED �The name of the ED provider �Specific instructions regarding activity and medications

Discharge Note Contents �What to expect going forward �Complementary tests �Whom and when to

Discharge Note Contents �What to expect going forward �Complementary tests �Whom and when to follow up �Warning symptoms for which to seek medical treatment or return to the ED �Asking patients to repeat the instructions given may help confirm their understanding

ED Discharge Sheet

ED Discharge Sheet

Leaving ED in Atypical fashion �Patients that leave the ED without being seen �Fail

Leaving ED in Atypical fashion �Patients that leave the ED without being seen �Fail to complete an ED visit (leave after being evaluated) �Sign out against medical advice (AMA)

What’s Your Idea? �They need more detailed documentasion �Document all interactions and conversations �They

What’s Your Idea? �They need more detailed documentasion �Document all interactions and conversations �They need to be evaluated more quickly and explained �They should receive discharge instructions as for optimal medical treatment

Important Items to Document �Thorough history and examination �Severity of illness and risks �Lack

Important Items to Document �Thorough history and examination �Severity of illness and risks �Lack of danger to self or others �Patient competency and capacity (lack of intoxication) �Patient understanding of the risks and benefits of leaving the ED �Understanding of Alternatives

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