Academic Clinical Discharge Summary Note

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SUBMIT ASSIGNMENTlopes-writeRequires LopesWriteStart Date Feb 17, 2022, 12:00 AM Due DateFeb 23, 2022, 11:59 PM Points 60 

Academic clinical discharge summary notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating an evidence-based plans of care.

This assignment uses a template. Refer to the “AGACNP Discharge Summary Template,” located on the Student Success Center page under the AGACNP tab.

Develop an academic clinical discharge summary note based on a hospital patient seen during clinical/practicum. The discharge summary note should include the following:

Rubric Criteria Description

Reason for Admission and Full Diagnosis

5. Target

4.2 points

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.

4. Acceptable

3.78 points

A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are present and include supporting details.

3. Approaching

3.36 points

A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are present.

2. Insufficient

2.1 points

A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are incomplete or incorrect.

1. 1: Unsatisfactory

0 points

A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are not included.

List of All Procedures

4.2 points

Criteria Description

List of All Procedures

5. Target

4.2 points

A list of all dates, significant findings, anesthetics, and contrast used during procedures is complete.

4. Acceptable

3.78 points

N/A

3. Approaching

3.36 points

N/A

2. Insufficient

2.1 points

A list of all dates, significant findings, anesthetics, and contrast used during procedures is incomplete.

1. 1: Unsatisfactory

0 points

A list of all dates, significant findings, anesthetics, and contrast used during procedures is not included.

Consults During Hospitalization

4.2 points

Criteria Description

Consults During Hospitalization

5. Target

4.2 points

A complete list of consults during hospitalization, including any providers or services consulted during the stay is complete.

4. Acceptable

3.78 points

N/A

3. Approaching

3.36 points

N/A

2. Insufficient

2.1 points

A list of consults during hospitalization, including any providers or services consulted during the stay, is incomplete.

1. 1: Unsatisfactory

0 points

A complete list of consults during hospitalization, including any providers or services consulted during the stay, is not included.

Condition of Patient at Discharge

4.2 points

Criteria Description

Condition of Patient at Discharge

5. Target

4.2 points

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.

4. Acceptable

3.78 points

Documentation of a physi

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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.

Academic Clinical Discharge Summary Note

SUBMIT ASSIGNMENT Requires LopesWriteStart Date Feb 17, 2022, 12:00 AM Due DateFeb 23, 2022, 11:59 PM Points 60 

Academic clinical discharge summary notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating an evidence-based plans of care.

This assignment uses a template. Refer to the “AGACNP Discharge Summary Template,” located on the Student Success Center page under the AGACNP tab.

Develop an academic clinical discharge summary note based on a hospital patient seen during clinical/practicum. The discharge summary note should include the following:

1. Reason for admission: Include the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis.

2. List of all procedures: Include all dates, significant findings, and any anesthetics and contrast used during procedures.

3. Complete list of consults during hospitalization: Include any providers or services consulted during the stay.

4. Patient’s condition at discharge: Include a physical exam prior to discharge that documents that patient is stable at discharge and has safe disposition and transportation. What diagnostic criteria confirmed the discharge diagnosis?

5. Complete list of discharge medications: Full list with all dosages, frequencies, and quantity of medications prescribed or dispensed.

6. Pending test results for follow up: Complete list of any pathology, cultures, radiology, or other diagnostic tests still pending, and who is responsible for follow-up on the final results.

7. Complete list of discharge instructions: Full list of directions regarding infection prevention, new medications, and returning to daily activities.

8. Complete list of discharge follow-ups: Full list of any therapies, treatments, referrals, consults, and follow-up appointments. What diagnostic criteria were needed after discharge?

9. Summary: What questions were raised during the hospital stay? Include all explanations and answers to these questions. What questions were raised that required further exploration? What kind of discharge planning did you need? Characterize your patient interaction activities.

10. Overall assessment: Identify health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes.

Incorporate three peer-reviewed articles in the assessment or plan.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, locate