Discharge Summary Electronic Medical Record

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Design and Hospitalwide Implementation of a …

https://pubmed.ncbi.nlm.nih.gov/28334559/

Background: The hospital discharge summary is the primary method used to communicate a patient's plan of care to the next provider(s). Despite the existence of regulations and guidelines outlining the optimal content for the discharge summary and …

Discharge summaries | Australian Digital Health Agency

https://www.digitalhealth.gov.au/initiatives-and-programs/my-health-record/whats-inside/information-healthcare-providers-can-upload/discharge-summaries

Discharge summaries can include: the name of the hospital or facility you were discharged from pathology tests problems/diagnoses clinical overview current medications on …

30 Hospital Discharge Summary Templates (& Examples)

https://templatearchive.com/discharge-summary/

A discharge summary template plays an important role in maintaining the safety of patients after getting discharged from the …

Electronic discharge summary (EDS) systems - Safety …

https://www.safetyandquality.gov.au/our-work/e-health-safety/electronic-discharge-summary-eds-systems

The National guidelines for on-screen presentation of discharge summaries specify the sequence, layout and format of the core elements of hospital discharge summaries, …

What Should Be Included in a Hospital Discharge …

https://blog.cureatr.com/what-should-be-included-in-a-hospital-discharge-summary

A discharge summary plays a crucial role in keeping patients safe after leaving a hospital. As an Advances in Patient Safety …

SNF Documentation Requirements - JE Part A - Noridian

https://med.noridianmedicare.com/web/jea/topics/documentation-requirements/skilled-nursing-facility-snf

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and …

How to Write a Discharge Summary - Geeky Medics

https://geekymedics.com/how-to-write-a-discharge-summary/

A discharge summary is a clinical report prepared by a health professional at the conclusion of a hospital stay or series of treatments. It is often the primary mode of communication between the hospital care team and …

Documentation Matters Toolkit | CMS

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Documentation

Documentation Matters Toolkit. Providers are responsible for documenting each patient encounter completely, accurately, and on time. Because providers rely on documentation to communicate …

42 CFR § 482.24 - Condition of participation: Medical …

https://www.law.cornell.edu/cfr/text/42/482.24

The organization of the medical record service must be appropriate to the scope and complexity of the services performed. The hospital must employ adequate personnel to …

Evaluation of an electronic health record structured …

https://qualitysafety.bmj.com/content/28/4/310

An electronic discharge summary with embedded data collection fields specifying surgical procedure and adverse events (complications) was developed by the section of Thoracic Surgery and Clinical Informatics …

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