Medical Transcription 13 Lecture Slides.pdf

Medical Correspondance & Report III

1. Medical Correspondance& Report III
Week 14: Discharge and Death Summaries
MEDICAL TRANSCRIPTION
DR EBENEZER ODURO ANTIRI

2. 2
•Discharge summaries are the final member of the “Big Four” family of medical
transcription reports.
•They’re among the most interesting to transcribe, because unlike other members of
the core four, they don’t leave you hanging, wondering how things turned out for the
patient.
•A History and Physical Examination (H&P) report tells you how the story starts but
then puts you on hold.
•Operative reports and Consultation reports provide glimpses of what happens in the
middle.
•A Discharge Summary wraps everything up into a nice, neat package.
•A Death Summary, of course, records the details of a patient’s final discharge
Discharge and Death Summaries
M E D I C A L C O R R E S P O N D A N C E & R E P O R T I I I

3. 3
•Each time a patient is released from a hospital, rehabilitation facility, or other in-
patient care setting, a Discharge Summary is generated.
•The patient may be going home, transferring to another facility, or sometimes just
moving to another department in the same facility.
•The Discharge Summary serves as a sort of patient hand-off document for whoever
sees the patient next.
Discharge Summaries
M E D I C A L C O R R E S P O N D A N C E & R E P O R T I I I

4. 4
•A Discharge Summary provides an overview of a patient’s hospitalization from
admission through discharge.
•It can be a few brief paragraphs or a multipage report, depending on the complexity
of the patient’s condition and treatment.
Overview
D I S C H A R G E S U M M A R I E S

5. 5
A typical report covers the following topics:
1.Admission and discharge dates
2.Names of physicians involved in the patient’s care
3.Initial and final diagnoses
4.Key laboratory and diagnostic data
5.A list of operations and medical procedures performed
6.A chronological narrative of the patient’s progress from admission through
discharge
7.Medications the patient is on at the time of discharge
8.The patient’s condition when discharged
9.Post-discharge instructions and plans
Overview
D I S C H A R G E S U M M A R I E S

6. 6
The layout, format, and sections included in a Discharge Summary vary between
facilities and sometimes even among dictators at the same facility.
The majority of the examples in this chapter comply with heading and layout styles
recommended in The Book of Style for Medical Transcription, 3rd Edition, by AHDI.
A few stray from The Book of Style to demonstrate other common layouts you’re likely
to encounter, such as a heading and data appearing on the same line rather than on
separate lines.
When transcribing, you should always format reports and headings as specified by the
account you’re working on, regardless of what standards might otherwise apply.
Discharge Summary
D I S C H A R G E S U M M A R I E S

7. 7
•The first thing a Discharge Summary does after stating the admission and discharge
dates is name names.
•The patient’s primary care provider gets top billing, followed by specialists involved
in the patient’s care.
•Some transcription platforms will insert the names automatically, but others will
require you to type some or all of it in.
•If it’s already present, confirm that it matches what’s dictated, because a finger slip
somewhere along the way can result in a wrong patient or physician ID being
entered into the system.
Discharge Summary
M E D I C A L C O R R E S P O N D A N C E & R E P O R T I I I

8. 8
•A typical Discharge Summary heading will start out like this:
PATIENT NAME: Newman, Anita
ADMITTED: 00/00/0000
DISCHARGED: 00/00/0000
PRIMARY CARE PHYSICIAN: Kerry Oakey, MD
NUTRITIONAL CONSULTANT: Holden D’Mayo, MD
A dictator may supply a department name instead of a person’s name:
CONSULTANTS: Nephrology and Hematology.
Discharge Summary
M E D I C A L C O R R E S P O N D A N C E & R E P O R T I I I

9. 9
•A Discharge Summary may include both Admission and Discharge Diagnoses or just
Discharge Diagnoses.
•They’re typically dictated in list form, usually near the beginning of the report.
•They should be formatted as a numbered list unless the facility specifies otherwise. If a
diagnosis is dictated using an abbreviation or acronym, it should be expanded to its full form
and followed by the acronym in parentheses.
•So, “DVT” becomes “deep venous thrombosis (DVT).”
•If the admitting and discharge diagnoses are identical, and the dictator may give them in one
fell swoop as Admission and Discharge Diagnoses.
•You should transcribe them as separate lists anyway. The quick and easy way is to copy the
admitting diagnoses list and change the title of the copy to Discharge Diagnoses.
Discharge Summary
M E D I C A L C O R R E S P O N D A N C E & R E P O R T I I I

10. 10
•Typical Admitting and Discharge Diagnoses lists look similar to this:
ADMISSION DIAGNOSES
1. Cerebrovascular accident (CVA) with left arm weakness.
2. Hyperlipidemia.
DISCHARGE DIAGNOSES
1. Cerebrovascular accident (CVA) with left arm weakness and MRI indicating
subacute infarct involving the right posterior parietal lobe.
2. Hyperlipidemia.
Discharge Summary
M E D I C A L C O R R E S P O N D A N C E & R E P O R T I I I

11. 11
•The History section, also dictated as History of Present Illness or Brief
History, provides introductory information about the patient and the
circumstances leading up to admission to the facility.
•It’s often essentially a reiteration of the same section from the patient’s
admitting History and Physical Examination (H&P) report, although perhaps
worded differently.
•Given the degree of overlap, dictators sometimes just reference the H&P
instead of repeating it.
History
D I S C H A R G E S U M M A R I E S

12. 12
BRIEF HISTORY A
3-year-old boy with a history of asthma. On the night of admission he
complained he was having trouble breathing, and his mother brought him to
the ER. He was noted to have subcostal retractions, expiratory wheezes, and
O2 saturation of 97% on room air. He was given albuterol nebulizer treatment
and subsequently admitted to the pediatric floor.
HISTORY OF PRESENT ILLNESS
Please refer to admitting History and Physical Examination for full details of
history and presentation.
History
D I S C H A R G E S U M M A R I E S

13. 13
The Hospital Course describes the patient’s progress and treatment between
admission and discharge, in chronological order.
HOSPITAL COURSE
The patient underwent L5-S1 Gill decompressive laminectomy and posterior lumbar
interbody fusion with pedicle screws with general anesthesia. She tolerated the
procedure well. She did complain of some persisting numbness in the S1 dermatome
of the right foot postoperatively. She was ambulatory, and her pain was under control
with oral analgesics at the time of her discharge.
A patient’s History of Present Illness and Hospital Course are frequently combined
under History and Hospital Course, Hospital Course, or Course in Hospital.
Hospital Course
D I S C H A R G E S U M M A R I E S

14. 14
The Laboratory Data section of a Discharge Summary includes only values
directly relevant to the patient’s diagnosis and treatment, not every test that
was administered.
A dictator may emphasize this point by titling this section Pertinent
Laboratory Data.
Diagnostic studies such as an MRI, CAT scan, and EKG often are dictated
along with the lab results.
Laboratory Data
D I S C H A R G E S U M M A R I E S

15. 15
However, if facility specifications permit it, it’s good practice to break them out
into a separate section with an appropriate heading, like this:
LABORATORY DATA ON ADMISSION
BMP unremarkable. White blood cell count 8.1, hemoglobin 12.0, hematocrit 36.2,
platelets 180,000. Urinalysis negative. Culture negative.
IMAGING
Principal imaging while in the hospital included CT of the head, which showed no
evidence of acute intracranial hemorrhage.
Laboratory Data
D I S C H A R G E S U M M A R I E S

16. 16
•This section lists major procedures or operations performed during the
patient’s hospitalization.
•It doesn’t include routine items such as starting an IV, only “big stuff” like
an operation, insertion of a feeding tube, or another special procedure.
•Principal Procedures Performed and Operations Performed are common
alternative titles for this section.
Procedures Performed
D I S C H A R G E S U M M A R I E S

17. 17
•When there’s only one procedure, it will look like one of these (depending
on how the facility prefers section headings to be formatted):
OPERATION PERFORMED
Right total knee replacement.
PROCEDURE PERFORMED: Right total knee replacement.
If there are multiple procedures, they should be listed vertically and numbered. As with
other numbered lists, end each line with a period. If a procedure name is dictated using
an acronym or abbreviation, expand it to its full form. For example, “LV angiogram”
would become “left ventricular (LV) angiogram.”
Procedures Performed
D I S C H A R G E S U M M A R I E S

18. 18
•A list of multiple procedures should look like this:
PROCEDURES PERFORMED
1. Left heart catheterization.
2. Coronary arteriogram.
3. Left ventricular (LV) angiogram.
4. Successful percutaneous transluminal coronary angioplasty (PTCA) of the
mid left anterior descending (LAD) stenosis, reducing it to about 20% to 30%.
Procedures Performed
D I S C H A R G E S U M M A R I E S

19. 19
•Most discharge summaries include a discharge physical examination.
•It usually pales in comparison to the formality and scope of an admitting
physical, but it often includes similar headings.
•A discharge exam may be limited to the body systems immediately
relevant to the patient’s diagnoses.
•Frequently, the discharge exam is expressed in paragraph format, even if
the admitting exam is customarily transcribed in a vertical format at the
same facility.
•When in doubt, check previous reports from the facility to confirm the
preferred layout.
Physical Examination on Discharge
D I S C H A R G E S U M M A R I E S

20. 20
An example of the Physical examination section transcribed:
PHYSICAL EXAMINATION
At the time of discharge vital signs were stable. HEENT: Pupils equal and reactive to
light. Extraocular movements normal. Neck: No JVD or bruits. CVS: S1, S2 normal.
Lungs: Clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended,
with positive bowel sounds. Extremities: No pedal edema. Neurologic: Nonfocal. Skin:
No rash. Surgical incision looks clean.
Physical Examination on Discharge
D I S C H A R G E S U M M A R I E S

21. 21
•Every discharge summary includes a list of medications the patient is
taking at the time of discharge.
•It includes medications the patient was already taking on admission and
incorporates modifications or additions.
•The items should be formatted as a numbered list with a period at the end
of each line.
1. Vitamin C 500 mg daily.
2. Symbicort 2 puffs twice a day.
3. Duragesic patch 25 mcg per hour q.72 h
Discharge Medications
D I S C H A R G E S U M M A R I E S

22. 22
•The final section of a Discharge Summary records the patient’s medical
status at the time of discharge and whether he’s going home or
somewhere else.
•If any follow-up appointments have been arranged, they may be listed here
as well.
•The topics may be broken out into separate headings or dictated as a
single paragraph, depending on the dictator’s habits and preference.
Plan/Disposition
D I S C H A R G E S U M M A R I E S

23. 23
•When dictated as individual sections, it will appear similar to this:
CONDITION ON DISCHARGE
Improved.
DISPOSITION
Discharged to home.
ACTIVITY
As tolerated.
When dictated under a single heading, it will resemble this instead:
PLAN His condition at the time of discharge is stable. Activity as tolerated. Diet is a
cardiac diet. Follow up with primary care physician.
Plan/Disposition
D I S C H A R G E S U M M A R I E S

24. 24
•Dictators may break out instructions given to the patient or a caretaker at
the time of discharge as a separate heading.
DISCHARGE INSTRUCTIONS
Maintain splint, clean, dry, and intact. Utilize ice to the left ankle as needed.
Follow up with Dr. Finklefiferon Monday at 8:30 a.m.
Discharge Instructions
D I S C H A R G E S U M M A R I E S

25. 25
•The previous sections are the most common, although they may be
dictated in a different order or use alternative wording for the headings.
•There are a few more you’ll encounter from time to time.
•Reason for Admission or Reason for Visit may be given near the top,
immediately before the History section.
•It states the reason for the patient’s admission in the briefest possible form:
REASON FOR ADMISSION: Renal colic.
Additional headings
D I S C H A R G E S U M M A R I E S

26. 26
•An allergies heading may be included, but usually only if the patient has
any:
ALLERGIES TO MEDICATION: CODEINE.
•Occasionally, especially if the patient is leaving the hospital in less than
ideal shape, a Prognosis heading is added.
PROGNOSIS: Poor.
Additional headings
D I S C H A R G E S U M M A R I E S

27. 27
•When a patient dies, the Discharge Summary becomes a Death Summary.
•Transcribing a Death Summary can be somewhat heart wrenching,
especially when it’s clearly sudden and unexpected or involves a child.
•Often the dictator’s tone of voice will reveal feelings of regret, although in
other cases the doctor is very matter of fact about it.
•Fortunately, Death Summaries are one of the least common report types.
Death Summary
M E D I C A L C O R R E S P O N D A N C E & R E P O R T I I I

28. 28
•A Death Summary contains a subset of the normal Discharge Summary
headings. Key differences include the following:
1.Discharge Date will be replaced by Date Expired or Date of Death.
2.Discharge Diagnoses will be replaced by Final Diagnoses.
3.Cause of Death may be dictated as an explicit heading.
•It’s common for a death summary to contain only Final Diagnoses and
Hospital Course sections.
•Occasionally, the dictator will give a narrative description with no headings
at all
Death Summary
M E D I C A L C O R R E S P O N D A N C E & R E P O R T I I I

29. Any questions?
Thanks!
29