FreeState Healthcare Discharge Summary

Date of Admission: [date name="variable_1" default=""]

Date of Discharge: [date name="variable_2" default=""]

Attending Physician: [checkbox name="variable_1" value="Elisha Yaghmai, MD|Hannah Bingham, MD|Aaron Olson, MD|Kristen Cline, MD|Manish Shah, MD"]

PCP: [checkbox name="variable_2" value="Unassigned"][textarea name="variable_1" default=""]

Admission Diagnosis: 
[textarea]

Discharge and Secondary Diagnoses:
[checkbox name="sbadc" value="Please see d/c dx list below."]
[textarea]

[checkbox name="Problem1" value="Consultations:"] [conditional field="Problem1" condition="(Problem1).is('Consultations:')"] 
[checkbox name="Problem2" value="None"] 
[checkbox name="Problem3" value="Cardiology:"] [conditional field="Problem3" condition="(Problem3).is('Cardiology:')"][textarea name="variable_20" default=""]
[checkbox name="Problem4" value="General Surgery:"] [conditional field="Problem4" condition="(Problem4).is('General Surgery:')"][textarea name="variable_21" default=""]
[checkbox name="Problem5" value="Psychiatry:"] [conditional field="Problem5" condition="(Problem5).is('Psychiatry:')"][textarea name="variable_22" default=""]
[checkbox name="Problem6" value="Neurology:"] [conditional field="Problem6" condition="(Problem6).is('Neurology:')"][textarea name="variable_23" default=""]
[checkbox name="Problem7" value="ID:"] [conditional field="Problem7" condition="(Problem7).is('ID:')"][textarea name="variable_24" default=""]
[checkbox name="Problem8" value="Ortho:"] [conditional field="Problem8" condition="(Problem8).is('Ortho:')"][textarea name="variable_25" default=""]
[/conditional]

Procedures and Diagnostics: 
[checkbox name="Procedures" value="None"][textarea name="Procedures_Box" default=""]

ADMIT HPI:
[textarea]

HOSPITAL COURSE:
[textarea]

[checkbox name="uncomplicated" value="Uncomplicated hospital course with expected results and response to therapy and treatment. No adverse outcomes during hospitalization.|Complications during hospitalization included:"][textarea name="complications" default=""]

[checkbox name="sbaobj" value="PHYSICAL EXAM:"][checkbox name="rrhobj" value="OBJECTIVE
*******************************************************************************"]
[textarea]

Pending Lab or Test Results: [checkbox name="lab" value="None|Pending labs include:"][textarea name="labs" default=""]

Discharge Disposition: [checkbox name="disposition" value="Home|Skilled nursing facility|Transfer to higher level of care|Psychiatric facility|Inpatient Rehab or Swingbed program|Expired|with home health|with hospice|per private car|via EMS|via secure transport/LEO|stable|unstable|guarded|critical"]

Diet: [checkbox name="diet" value="As tolerated|Bland|Soft|Dysphagia|Diabetic|Cardiac|Renal|Regular|Return to pre-hospital diet"]

Activity: [checkbox name="Activity" value="As tolerated|With Walker|Non-weight bearing|Per ortho"]

[checkbox name="Seen_discharge" value="The patient was seen and examined by me on day of discharge.|The patient was not seen by me on day of discharge."]
[comment memo="Additional Discharge Instructions, Appointments or Comments"]
[checkbox name="Problem83458" value="Follow Up Appointments:"] [conditional field="Problem83458" condition="(Problem83458).is('Follow Up Appointments:')"] 
[checkbox name="variable_45671" value="Follow up with primary care as soon as possible after discharge.|Follow up with primary care 3-5 days after discharge.|Follow up with primary care 5-7 days after discharge."]
[textarea name="variable_546" default=""] [date name="variable_654" default=""]
[checkbox name="variable_1245" value="Their office will reach out to the patient to schedule an outpatient appointment.|Patient has stated that they will call the office and arrange for a follow up as recommended."][/conditional]

[checkbox name="Problem5667" value="Recommended OP Labs/Diagnostics:"] [conditional field="Problem5667" condition="(Problem5667).is('Recommended OP Labs/Diagnostics:')"] 
[checkbox name="variable_32456" value="We recommend the following labs/diagnostics after discharge:"] 
[textarea][/conditional]

[textarea] 

[comment memo="Discharge to Home"]
[checkbox name="dispo_home" value="Strict return precautions discussed with patient. Education regarding s/s of worsening or returning condition discussed. Patient verbalizes understanding of returning immediately with any concerns. Reports understanding of following up as directed and taking all prescriptions and treatments as directed.|Discharge time included education regarding disease process, all prescriptions, importance of scheduled follow up, continuity of care communication with PCP, preparation/provision of prescriptions for medications."]
[comment memo="Transfer to Tertiary"]
[checkbox name="dispo_transfer" value="Patient requires additional testing and specialty consultation not available at this facility. Patient will require transfer to tertiary care facility.|Patient required transfer due to lack of available beds and/or staffing at this facility.|Discharge time included the provision of services needed to safely and efficiently arrange for transport of patient to a tertiary care facility including consultations, discussion of plan with patient/family, and coordination of discharge."]

Discharge time is [select name="variable_1" value="less|more"] than 30 minutes with patient

For a list of discharge medications, follow up appointments, and patient education/instructions, please see the "Discharge Instructions" document in the EHR.

[checkbox name="Problem70" value="Discharge completed by NP/PA."][conditional field="Problem70" condition="(Problem70).is('Discharge completed by NP/PA.')"] Discharge discussed with attending physician [checkbox value="Elisha Yaghmai, MD|Hannah Bingham, MD|Aaron Olson, MD|Kristen Cline, MD|Manish Shah, MD"] who agrees with plan.[/conditional]