Patient Directed Discharge
!!!!!!!!!!!!!!!!!!!!!!! PATIENT-ELECTED DISCHARGE PATIENT IS ELECTING TO STOP IN-HOSPITAL TREATMENT AND IS LEAVING THE HOSPITAL DESPITE MEDICAL ADVICE TO REMAIN INPATIENT AND CONTINUE TREATMENT IN THE HOSPITAL. !!!!!!!!!!!!!!!!!!!!!!! The patient has elected to stop in-hospital medical treatment and has elected to discharge from the hospital despite medical advice to remian inpatient and continue treatment in the hospital. I explained the risks of the patient's elected choice, including worsening infection, septic shock, and death. The patient has capacity, voiced understanding of the risks of their decision, and was able to explain these risks back to me.
I explained that I may prescribe oral antibiotics on discharge, but these oral antibiotics are NOT proven effective for the patient's type of infection, and the patient still has very high risks of sepsis and death despite these oral antibiotics. Again, the patient voiced understanding of these risks, and was able to explain these risks back to me.
Against Medical Advice
!!!!!!!!!!!!!!!!!!!!!!! PATIENT IS REFUSING TO CONTINUE TREATMENT IN THE HOSPITAL AND IS LEAVING THE HOSPITAL AGAINST MEDICAL ADVICE !!!!!!!!!!!!!!!!!!!!!!! The patient is leaving the hospital against medical advice. I explained the risks of leaving against medical advice, including worsening infection, septic shock, and death. The patient has capacity, voiced understanding of the risks of leaving against medical advice, and was able to explain these risks back to me.
I explained that I may prescribe oral antibiotics on discharge, but these oral antibiotics are NOT proven effective for the patient's type of infection, and the patient still has very high risks of sepsis and death despite these oral antibiotics. Again, the patient voiced understanding of these risks, and was able to explain these risks back to me.
Death
BRIEF DEATH NOTE Called to bedside by nursing for cessation of respirations. Patient was in bed, and on examinatio there was no chest rise, ho heart or breath sounds to auscultation, no response to physical or verbal stimulus. No palpable pulses. Eyes were fixed and dilated, with no corneal response. The patient is DNR/DNI and no attempt at resuscuitation was made. Time of Death was xxxx on xxxx Family was contacted and notified, and they declined autopsy.
Physical Exam for death
HEENT: Eyes fixed and unresponsive, no corneal response Cardiovascular: no heart sounds, no pulses, no lower extremity edema Pulmonary: no breath sounds, no chest rise Abdom: no bowel sounds
Patient Discharge Instructions
General
Resume all of your home medications with the following exceptions: START THESE NEW MEDICATIONS: STOP THESE MEDICATIONS: CHANGE THE DOSE OF THESE MEDICATIONS: Make sure to go to all follow-up appointments. Your hospital plan of care includes these followup clinic appointments - they are necessary to ensure you continue to recover. In particular, your appointments include - xxxxxx There may be other appointments, and you should go to any previously scheduled appointments as well. There are several labs that have not completed at the time of discharge. - xxxxxx Please make sure to discuss these results when they are available with your physicians. Make sure to go to all follow-up appointments. Your hospital plan of care includes these followup clinic appointments - they are necessary to ensure you continue to recover. After you return home, make sure to take only the medications listed in your discharge summary. Some medications you took before the hospital may have been stopped or changed in dose. Also, you may be started on new medications. All of these changes will be described to you before you leave the hospital. Follow a low fat and low salt diet Go to the nearest ER immediately if you have any of the following: New chest pain or shortness of breath Bleeding or severe bruising Confusion Increased or severe pain Blue lips or fingernails Go to your primary doctor if you have any of the following: Fever of 101 degrees or more Nausea or vomiting Constipation or diarrhea major weight loss or gain (more than 5 lbs in 1 week or more than 10 lbs in 1 month) More than normal mucous production, or yellow, green or smelly sputum
Low Potassium Diet
Instructions for avoiding dangerous potassium levels: Follow a Low potassium diet - avoid oranges and orange juice - avoid tomatoes and tomato juice (including V8) - avoid bananas - avoid all salt substitutes (such as Mrs Dash)
No NSAIDs
Instructions for protecting your kidneys: Avoid all Non-steroidal Anti-Inflammatories (NSAIDs) including Ibuprofen or Advil or Motrin or Nuprin, Naproxen or Alleve, Ketorolac or Toradol, Diclofenac or Voltaren
Quit Smoking
Quit Smoking
One of the healthiest things you can do for yourself is to stop smoking.
That includes cigarettes, vaping, chewing or any smokeless tobacco, cigars and pipes.
No matter your age or how long you have smoked, it is never too late to quit, and you are never too old to benefit from quitting.
Over time, people who quit smoking see many benefits to their health. After you smoke your last cigarette, your body begins a series of positive changes that continue for years.
Time after quitting Health benefits
=================== ===============
Minutes Heart rate drops
24 hours Nicotine level in the blood drops to zero
Several days Carbon monoxide level in the blood drops to level of someone who does not smoke
1 to 12 months Coughing and shortness of breath decrease
1 to 2 years Risk of heart attack drops sharply
3 to 6 years Added risk of coronary heart disease drops by half
5 to 10 years Added risk of cancers of the mouth, throat, and voice box drops by half. Risk of stroke decreases
10 years Added risk of lung cancer drops by half after 10-15 years.
Risk of cancers of the bladder, esophagus, and kidney decreases
15 years Risk of coronary heart disease drops to close to that of someone who does not smoke
20 years Risk of cancers of the mouth, throat, and voice box drops to close to that of someone who does not smoke.
Risk of pancreatic cancer drops to close to that of someone who does not smoke.
Added risk of cervical cancer drops by about half
Seizure Precautions
Seizure Precautions - Do not drive for at least 90 days after most recent seizure/spell or until cleared by a medical authority - No operating heavy machinery or power tools - Avoid open flame include operating flame torches of any kind - Avoid situations where loss of awareness may risk injury - No baths (showers only) - Avoid swimming alone and avoid open bodies of water - Avoid sleep deprivation or other known seizure risk factors including alcohol
PRN Diuretics
Instructions for monitoring your body water
- Weigh yourself before breakfast on the first full day home. This is your dry weight. Your latest estimated dry weight in the hospital was
- Weigh yourself before breakfast every morning.
If your weight has increased by 6 pounds or more in the previous 3 days, then take one extra Furosemide tablet.
If your weight has increased by 10 pounds or more in the previous 3 days, then also call your primary care doctor
- Take diuretics in the morning
COVID Patients
Resume all of your home medications with the following exceptions: START THESE NEW MEDICATIONS: STOP THESE MEDICATIONS: CHANGE THE DOSE OF THESE MEDICATIONS: When you go home, continue to self-quarantine until XXXXXXXX You will need to use your own bathroom and bedroom that are not shared with other people. Make sure to go to all follow-up appointments. Your hospital plan of care includes these followup clinic appointments - they are necessary to ensure you continue to recover. After you return home, make sure to take only the medications listed in your discharge summary. Some medications you took before the hospital may have been stopped or changed in dose. Also, you may be started on new medications. All of these changes will be described to you before you leave the hospital. Call your Primary Care physician or go to the nearest Emergency Department if you have any of these: - Fevers greater than 100.5 - Worsening cough or difficulty breathing - Nausea, vomiting or diarrhea
Migraines
Instructions for Migraine Headaches - Keep a headache diary, so you know how many days in each month you had a migraine and look for triggers - Avoid common triggers such as Any tobacco (smoking, smokeless, more) Alcohol - Get regular amount of sleep (typically 8 hours) and go to bed at the same time each night - Eat three meals a day, and at the same time each day. Do not let yourself get too hungry or skip meals
Sliding Scale Insulin
While inpatient the patient was on sliding scale insulin but will resume their home diabetes medications on discharge.
Coder Request
This note is to respond to a coding query request. This does not affect plan of care for the patient but is used for administrative purposes only.GENERAL
This is useful when you are writing only the Hospital Course section of a form.
NEW DIAGNOSES ------------------------------------------ MEDICATION CHANGES ON DISCHARGE ------------------------------------------ TESTS NEEDING FOLLOWUP IN CLINIC (tests done while in hospital but results are still pending at time of discharge) ------------------------------------------ TESTS and PROCEDURES TO BE DONE AFTER DISCHARGE ------------------------------------------ FOLLOW-UP APPOINTMENTS AFTER DISCHARGE ------------------------------------------ ACTIVE PROBLEMS ADDRESSED IN THE HOSPITAL ------------------------------------------
Entire Document
Discharge Summary
MEDICINE DISCHARGE SUMMARY DATE OF ADMISSION: DATE OF DISCHARGE: PRIMARY TEAM: STAFF PHYSICIAN: CONSULTATIONS: PROCEDURES: IMAGING: HISTORY OF PRESENT ILLNESS: HOSPITAL COURSE: #) Continued to receive home medications xxxx and this was stable throughout the hospital stay. Home medication xxxxx was initially held while xxxxx, but will be resumed on discharge. ADMISSION PHYSICAL EXAM: DISCHARGE PHYSICAL EXAM: DISCHARGE MEDICATIONS: START THESE NEW MEDICATIONS: STOP THESE MEDICATIONS: CHANGE THE DOSE OF THESE MEDICATIONS: Continue all other previous home medications at their previous dose DISCHARGE INSTRUCTIONS: - Take all medications as prescribed - Go to all scheduled followup appointments - Follow a low fat and low salt diet - Go to the nearest ER immediately if you have any of the following: New chest pain or shortness of breath Bleeding or severe bruising Confusion Increased or severe pain Blue lips or fingernails - Go to your primary doctor if you have any of the following: Fever of 101 degrees or more Nausea or vomiting Constipation or diarrhea major weight loss or gain (more than 5 lbs in 1 week or more than 10 lbs in 1 month) More than normal mucous production, or yellow, green or smelly sputum FOLLOWUP APPOINTMENTS: - Primary Care Medicine within 1 week of hospital discharge TESTS PENDING AT DISCHARGE: - None