Against Medical Advice



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PATIENT IS REFUSING TO CONTINUE TREATMENT IN THE HOSPITAL AND IS LEAVING THE HOSPITAL AGAINST MEDICAL ADVICE
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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 we 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.




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.

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


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
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MEDICATION CHANGES ON DISCHARGE
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TESTS NEEDING FOLLOWUP IN CLINIC 
(tests done while in hospital but results are still pending at time of discharge)
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TESTS and PROCEDURES TO BE DONE AFTER DISCHARGE
------------------------------------------



FOLLOW-UP APPOINTMENTS AFTER DISCHARGE
------------------------------------------



ACTIVE PROBLEMS ADDRESSED IN THE HOSPITAL
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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