Question

A patient's record contains the following order: "Mary Black is stable and has no complaint of pain. Wound is healing. No fever or chills. No medications given and no restrictions. She can be released home in the morning. To be seen in my office in two weeks." This is an example of a

a) Progress note
b) Discharge summary
c) Admission note
d) Consultation report

Answer 1

The record of Mary Black being stable, with a healing wound and instructions for release and follow-up, is a discharge summary. It encapsulates her treatment and care during the hospital stay and gives post-discharge instructions.

Step-by-step explanation:

The patient record you mentioned that indicates Mary Black can be released in the morning and is to be seen in the office in two weeks is an example of a discharge summary. A discharge summary is a medical document that provides an overview of a patient's hospital stay, including their condition, treatment received, and instructions for follow-up care. In this case, Mary Black is deemed stable with no complaints and is recommended for release home in the morning, with an appointment scheduled for two weeks later. A discharge summary is a comprehensive clinical report created when a patient is being released from the hospital to home or another form of care. It summarizes the patient’s admission, the course of treatment during their stay, their current condition at discharge, and recommendations for follow-up care.