Discharge Summary?
Posted By: Diana on 2009-06-05
In Reply to:
Subject: Discharge Summary?
I'm practicing an assignment for my class and I figured this was the best place to post a question about it.
I know that it's a discharge summary but I'm completely stumped as to the layout. It doesn't seem to fit the layouts in my books so I don't know what I should do. I don't want to get a bad grade on the assignment and would love to get the format right the first time.
If anybody is willing to, I would love to e-mail the file to you so you can possibly give me an idea?
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Discharge summary
Subject: Discharge summary
A diagnosis of pneumomediastinum, presumed from catheter placement, was made. An x-ray showed air under the (high , five, thigh) diaphragm. I can't make out what he's saying here, but those are the words it sounds like he's saying. Thanks.
A discharge summary. Thank you
Subject: A discharge summary. Thank you
x
discharge summary
Subject: discharge summary
pt. had cardiac cath
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discharge summary help
Subject: discharge summary help
Patient is a 46-year-old white female with past medical history significant for motor vehicle accident in 1976 with closed head injury profound mental retardation. Since then *** feedings at home. Started to have diarrhea a week prior to her admission S/L "onfactive" feedings at home any suggestions? thanks so much!!!
is this an OP or a discharge summary or what?
Subject: is this an OP or a discharge summary or what?
it is a discharge summary
Subject: it is a discharge summary
discharge summary
Subject: discharge summary
could possibly be "discharging Marcus John Doe" i.e. discharge summary?
discharge summary
Subject: discharge summary
I am working on a Discharge Summary and in the medication list "folic 12.5 one p.o. b.i.d." is listed. (This is a male pt.) I can't find 12.5 as a dosage available anywhere and also, isn't "folic" as in folic acid usually for women? the diagnoses are.... chf, cellulitis, cardiomyopathy and morbid obesity. I don't see what "folic" would be prescribed for. Any ideas? Thanks, this is driving me crazy!
discharge summary
Subject: discharge summary
I cannot make out this word at all. Any suggestions?
On admission his INR and PTT were both elevated and his hemoglobin and hematocrit were 12.9 and 38.1. We applied pressure dressingand gave 4 units of plasma. We then gave subcutaneous Vitamin K. The bleeding has stopped and we have *bal ized tip* and are sending him home on outpatient dialysis.
discharge summary
Subject: discharge summary
stabilized him?
discharge summary help
Subject: discharge summary help
does this sound right?
On admission his INR and PTT were elevated. His hemoglobin and hematocrit were 13.2 and 37.2. We applied pressure dressing and gave 7 units of fresh frozen plasma with vitamin K. The bleeding has since stopped overnight and we have *dialyzed him* this morning. We are sending him home to continue with his outpatient dialysis schedule.
word help please discharge summary
Subject: word help please discharge summary
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Discharge Summary Abbreviations
Subject: Discharge Summary Abbreviations
Must we expand all abbreviations in the Discharge Summary (as you would in a diagnosis/impression), or type verbatim?
Psych Discharge Summary
Subject: Psych Discharge Summary
Patient is status post total knee replacement and doctor is dictating regarding Hospital Course: She states, after preoperative medical clearance the patient was admitted. The patient underwent a lateral _______ of the left knee. S/L lateral litho of the left knee. She is really garbled. Any help would be appreciated. Thanks.
Psych Discharge Summary
Subject: Psych Discharge Summary
Thank you, thank you, thank you. I feel so braindead sometimes. It's like I just can't understand one more word.
Just a discharge summary stating pt had a uti with that type of bacteria, but nothing else.
Subject: Just a discharge summary stating pt had a uti with that type of bacteria, but nothing else.
xx
Discarge summary
Subject: Discarge summary
Eyes: The eyes have discharged bilaterally.
Could that be what he's saying?
S/L: M/S/S Hx: See summary report
Subject: S/L: M/S/S Hx: See summary report
any idea as to what this abbreviation could be? M/S/S Hx: See summary report.
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discharge
Subject: discharge
They eyes have discharge bilaterally. (secretions etc)
discharge
Subject: discharge
DISCHARGE DIAGNOSES:
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2. PAS.
3. HD with recent stints.
4. GI bleed, post stint.
discharge med.
Subject: discharge med.
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Subject: Preemie discharge
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HPs, Consults, Ops and Discharge
Subject: HPs, Consults, Ops and Discharge
Summaries. Is that what you are looking for?
discharge, drainage, or pus IMO nm
Subject: discharge, drainage, or pus IMO nm
x
discharge medications
Subject: discharge medications
When this doctor is dictating the discharge medications it sounds like she is saying Claritin 10 mg 2 PEG once a day. The patient is on PEG tube. Could that be it? Never heard that before.
Yes, it's discharge diagnoses-First
Subject: Yes, it's discharge diagnoses-First
one is enterobacter septicemia due to line infection.
Not sure. In the discharge meds. PT has
Subject: Not sure. In the discharge meds. PT has
1. Folliculitis.
2. Oral thrush.
3. Congestive heart failure exacerbation.
4. Mastoiditis.
5. Bilateral upper lobe pneumonia. Rule out tuberculosis.
6. HIV/AIDS.
7. Urinary tract infection.
MSIR discharge RX
Subject: MSIR discharge RX
He lists it as one of her current (discharge) meds--go figure. I certainly appreciate the help.
Seems odd to me...
discharge medication
Subject: discharge medication
I cannot find reference to this medication anywhere, but it sounds like "quinopen 30.5 mg p.o. nightly."
Any ideas?
Discharge status
Subject: Discharge status
Psychiatric discharge summary: Sounds like OPT NSD 'discharge'.
He's probably saying suppuration or discharge of pus from the ear.
Subject: He's probably saying suppuration or discharge of pus from the ear.
^-^
Under discharge medications, the doc says:
Subject: Under discharge medications, the doc says:
Nutritional supplement L shakes b.i.d.
Nipple discharge/Ductogram
Subject: Nipple discharge/Ductogram
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TIA!
Sorry, no. It was just listed on the discharge meds; sm
Subject: Sorry, no. It was just listed on the discharge meds; sm
Patient has hypertension, has MI while admitted, anemia, tardive dyskinesia, SSS, and hypothyroidism; all the other meds listed seemed to have covered these problems. I did a google search and searched RXlist and came up with nothing. Also have the most recent version of quarterly drug index and can't find anything there either! TIA
It's a list of discharge diagnoses...
Subject: It's a list of discharge diagnoses...
DKA, then s/l Right leg varicose, then obesity. He says it later in the report and it definitely s/l varicose.
it is part of discharge medications ....
Subject: it is part of discharge medications ....
but also in discharge summary under hospital course he mentions, "All his home inhalers including his s/l spidy one albuterol was continued." I haven't got a clue on this. Thanks.
part of discharge diagnoes... sm
Subject: part of discharge diagnoes... sm
Renal wheezing? Poor guy has a whole host of urological complaints, but I can't find renal wheezing anywhere! TIA!
HELP! Kolophonic discharge?? (sinusitis)
Subject: HELP! Kolophonic discharge?? (sinusitis)
mild kolophonic discharge (talking about sinus symptoms). THANKS!!
ophthalmology-discharge report...
Subject: ophthalmology-discharge report...
'Disk culture: See details like cup-to-disk ratio or the macula. Vessels were normal and the peripheral it was noted for retinoschisis with the barrier laces surrounding the posterior edge in a 360 degree fashion.'
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leukorrhea is vaginal discharge though
Subject: leukorrhea is vaginal discharge though
This is a male, and it is definitely referring to urine. Thanks, though. It does sound close.
The patient has no discharge, drainage, or pus.
Subject: The patient has no discharge, drainage, or pus.
On discharge note after bariatric
Subject: On discharge note after bariatric
surgery - "was found to have patulous GE junction. s/l ZEELINE was thought to be elevated.
Appreciate any thoughts.
Thanks!
I would put "nasal or oral discharge..."
Subject: I would put "nasal or oral discharge..."
DISCHARGE DIET: 2 peas???
Subject: DISCHARGE DIET: 2 peas???
This is for a patient who had a laryngectomy. This is all the information he dictates for the diet. 
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Subject: suppuration = formation or discharge of pus
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Subject: ?Through ostometer? has been more liquid discharge.
NA
probably coryza, results in nasal discharge. nm
Subject: probably coryza, results in nasal discharge. nm
x
Starting to sound more like cobblestone discharge. I think this is it...?
Subject: Starting to sound more like cobblestone discharge. I think this is it...?
nm
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Subject: The surgical wound had dry, s/l semuous discharge. TIA
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Subject: Patient with vaginal discharge, need help with lab term - sm
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Question about slide done breast discharge sm
Subject: Question about slide done breast discharge sm
Slide was done of this area, with s/l "cyto Fixodent" done. I can't find anything, other than related to Fixodent for false teeth. Thanks for any help.
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