Academic discharge clinical summary note

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AGACNP Discharge Summary Template

Reason for Admission: A description of the reason for admission, a list of diagnoses in order of

acuity, and an ICD-10 diagnosis are thorough and include substantial supporting details.

List of All Procedures: A list of all dates, significant findings, anesthetics, and contrast used

during procedures.

Consults During Hospitalization: A complete list of consults during hospitalization, including

any providers or services consulted during the stay.

Condition of Patient at Discharge: Documentation of a physical exam prior to patient discharge

that notes the safety and stability of the patient, in addition to any diagnostic criteria that

confirmed the discharge diagnosis, is thorough and includes substantial supporting details.

Discharge Medications: A full list of discharge medications that includes all dosages,

frequencies, and quantities of medications prescribed or dispensed.

Pending Test Results for Follow-Up: A complete list of any pathology, cultures, radiology, or

other diagnostic tests still pending, including an indication of who is responsible for follow-up

on results.

Discharge Instructions: Directions regarding infection prevention, new medications, and

returning to daily activities are thorough and include substantial supporting details.

Discharge Follow-Ups: Therapies, treatments, referrals, consults, and follow-up appointments,

in addition to any diagnostic criteria, needed after discharge.

Summary: Address questions raised during the hospital stay, in addition to a discussion about

questions requiring further exploration, discharge planning, and patient interaction activities.

Overall Assessment: Identification of health promotions, health education, ethical

considerations, and expected outcomes is thorough and includes substantial supporting details.

Geriatric Considerations: Based on the patient's age, address any differences in the treatment if

the patient were younger or older.

References: Listed in APA format. Use three sources to justify your discharge plan.