Discharge DocumentationOjaghi Haghighi M.D

Why Discharge Note?Medico-legal risk

Patient comprehension about the diagnosis & performed measures

Patient adherence to medical advice

Proper follow up

Helping the next physician for effective treatment & continuity of care

Discharge Note ContentsBoth verbally and in printed form (brightly colored

papers)

Given diagnosis (or diagnoses)

What was done in the ED

The name of the ED provider

Specific instructions regarding activity and

medications

Discharge Note ContentsWhat to expect going forward

Complementary tests

Whom and when to follow up

Warning symptoms for which to seek medical treatment or return to the ED

Asking patients to repeat the instructions given may help confirm their understanding

ED Discharge Sheet

Leaving ED in Atypical fashionPatients that leave the ED without being seen

Fail to complete an ED visit (leave after being evaluated)

Sign out against medical advice (AMA)

What’s Your Idea?They need more detailed documentasion

Document all interactions and conversations

They need to be evaluated more quickly and explained

They should receive discharge instructions as for optimal medical treatment

Important Items to DocumentThorough history and examination

Severity of illness and risks

Lack of danger to self or others

Patient competency and capacity (lack of intoxication)

Patient understanding of the risks and benefits of leaving the ED

Understanding of Alternatives