Ojaghi Haghighi M.D. Why Discharge Note? Medico-legal risk Patient comprehension about the diagnosis & performed measures Patient adherence to medical.

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Presentation transcript:

Ojaghi Haghighi M.D

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 (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 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

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 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 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