What should a discharge summary look like? Watch this video and learn when and why to release the patient from active care. Included here are documentation examples of what is expected in a final written discharge summary and how to document the patient’s current condition in comparison to the initial presentation.
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Know When it’s Time to Discharge When a patient is nearing completion of an active episode of care, it can be difficult to know when it’s time for discharge. It’s an age-old question that is rooted in proper case management. The patient may be released with or without symptoms, and a prognosis of possible exacerbations…
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This short video teaches you the value of therapeutic withdrawal not only for clinical purposes but also as a good documentation practice. The intention and definition of therapeutic withdrawal are important to understand and document. This rapid tutorial provides examples of how to document the patient visit when you have decided that therapeutic withdrawal is…
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In the world of documenting an episode of care, the end of the episode is just as important as the beginning. As you have seen previously in this module, laying out a sound initial visit note sets the stage for compliant documentation through the entire episode, leading into the progress exams, and eventually to the…
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Download Reference Documents The reference documents for this module encompass multiple practice guidelines, definitions, and documentation requirements. Please note that some of these resources are in other courses in this module as they have relevance to more than one aspect of the various parts of documenting an initial visit note, periodic re-evaluation, and discharge exam….
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Download Support Tools These are documentation samples of the components necessary for a periodic re-evaluation to be noted in the patient medical record. In the sidebar you’ll find the reasoning for the individual pieces needed to create the best possible written account of how the patient in progressing. These re-evaluation documentation examples offer various formats…
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