Task 1.6: How to Develop a Discharge Summary

Dr. Campbell has delivered some difficult news and asked you to complete a discharge summary for Ella Cruz. The steps below will help you complete this task.

Getting Started

1. If you have not already done so, go to the meeting with Dr. Campbell by clicking on the "go to the meeting" button under the email.
   
   
2. After viewing the video, download Dr. Campbell's notes and form noted on the links below the "go to meeting" button.
   
   
3. Carefully review both Dr. Campbell's notes (Patient Autopsy Report) as well as the Discharge Summary Form.
• As always, if there are any terms or notations that are unfamiliar to you in either of these documents, conduct research either through DATA in the Resources link (above) or through other sources for a full understanding of the material.
  
  
4. Meet with your team to discuss the news and also make a plan for the task ahead.

Completing the Patient Discharge Summary

1. Look back over your notes and any prior information in this rotation to collect the information requested in each section. You may view video again, or look at any document you have used or created throughout the rotation to complete this form accurately.
   
   
   • In the "Presenting Symptoms" section, include the original reason for coming to the hospital, preferably in the patient's own words.
   • In the "Physical Exam Findings" section, only abnormal results need be included.
   • In the "Laboratory Findings" section, include all results with analysis.
   • In the "Diagnosis" section, include the thinking behind what you estimated to be the top diagnosis at the time of Ella's event.
   • In the "Treatment" section, include all relevant treatments.
   • "Cause of Death" should include a detailed analysis of the reason for Ella's death.
     
     
     
2. Review the document as a team, and make revisions accordingly.

Review and Submit Your Work

1. Review Your Work.
   • Did you thoroughly review the Autopsy Notes and apply some of the information to the Discharge Summary?
   • Did you discuss the progression of the case with your team to prepare for the work during the task?
   • Did you complete the Discharge Summary Form?
2. Submit Your Work.
   • Review the checklist located in the Submit your work section of this task to ensure completion of the task before submitting your deliverables to your mentor.

Meeting to Exchange Feedback

1. Meet with your cohort to discuss your findings and ideas. Your mentor will assign your team one or more diagnoses at the beginning of the meeting. Your team will present your key ideas and lead the discussion of those diagnoses.
   
   
   • Jot down notes to record what you gain from the discussion. Write any answers you found to the questions you and your teammates posed in the beginning of this task. You may also note down any questions you still have about analyzing tests and making a diagnosis.
     
     
2. After incorporating any feedback you may have received during the discussion, submit your work to your mentor. Be sure to save all of your work, regardless of whether you submit it to the mentor.
   

Diagnosis and Treatment Archive (DATA) - Mystery Case

Diagnosis and Treatment Process
This document describes the process that health care professionals typically use to diagnose and treat their patients.