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

Develop an academic clinical discharge summary note based on a hospital patient seen during clinical. The discharge summary note should include the following: ( Acute Care Hospital)

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 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 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 3-5 peer-reviewed articles in the assessment or plan. (Minimum 1000 words).

Don’t Forget to include all coding including ICD-10, CPT and all others.

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, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

Academic Clinical Discharge Summary Note

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

Develop an academic clinical discharge summary note based on a hospital patient seen during clinical. The discharge summary note should include the following: ( Acute Care Hospital)

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 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 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 3-5 peer-reviewed articles in the assessment or plan. (Minimum 1000 words).




Don’t Forget to include all coding including ICD-10, CPT and all others.

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

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Academic Clinical Discharge Summary Note

Muhammad Aftkhar

Grand Canyon University

February 15th, 2021


Academic Clinical Discharge Summary Note

Reason for admission

A 62 years old male patient came with a dull throbbing pain in the right upper abdominal region. The patient was somewhat nervous due to stabbing pain. The pain scale was eight. The patient reached the hospital with his daughter. Upon physical examination, there was swelling on the upper right abdomen and pain radiating towards the shoulder blade. The other reported symptoms were fatigue, yellowing of the skin, loss of appetite, and swollen ankles (Chen, et al., 2020). Laparoscopic examination of the liver suggested that focal hepatocellular necrosis was present. Additionally, Nodular regeneration and distortion of hepatic texture were also observed. Macronodules with a size of 5 mm were also observed. Moreover, Ultrasound indicated the surface nodularity with 88% sensitivity.

ICD 10 Diagnosis

· Liver cirrhosis (K74.60)

· Celiac disease (K90)

· Autoimmune hepatitis (K75.4)

· Hepatocellular carcinoma (155)

· Primary biliary cirrhosis (K74.3)

List of all procedures:

· Band ligation (CPT Code = 46221)

· Transjugular intrahepatic portosystemic shunting (TIPS) (CPT Code = 37182)

· Splenorenal shunt (CPT Code = 37205)

· Paracentesis (CPT Code = 49082)

· Liver transplantation (CPT Code = 47135)

The progression of liver cirrhosis often results in portal hypertension that ultimately led to esophageal varices. When the portal pressure increases from 7 mmHg, variceal bleeding occurs. Therefore, Variceal band ligation is the primary procedure to manage the complications. Similarly, TIPS is used to control variceal bleeding to increase the survival of the patient. Moreover, the splenorenal shunt is used to limit the recurrent variceal hemorrhage. When the patient has a splenorenal shunt, there is significant control of portal hypertension. In this surgical procedure, the patient is also given general anesthesia, and the vein from the spleen is disconnected from the portal vein and re-joined to the renal vein. However, when all the mentioned procedures become ineffective, then hepatic transplantation is required to replace the fibrotic part of the liver with a healthy liver. All the procedures make use of contrasted enhanced intraoperative ultrasonography.

Complete list of consults during hospitalization:

· Post-surgical consultation for pain management

· Instructions for TIPS to avoid any complications due to shunt.

· The physician consult for antibiotic to prevent infection from ascites

· Pharma consults for drug treatment

· Asc

Rubic_Print_Format

Course Code Class Code Assignment Title Total Points
ANP-650 ANP-650-XO0103XB Academic Clinical Discharge Summary Note 65.0
Criteria Percentage Excellent (100.00%)
Content 70.0%
Reason for Admission and Full Diagnosis 10.0% A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are extremely thorough and include substantial supporting details.
All Procedures 10.0% A list of all dates, significant findings, any anesthetics, and contrast used during procedures is present.
Consults During Hospitalization 10.0% A complete list of consults during hospitalization, including any providers or services consulted during stay is present.
Condition of Patient at Discharge 10.0% A physical exam prior to discharge that documents patient is stable at discharge and has safe disposition and transportation is present.
Discharge Medications 10.0% A full list with all dosages, frequencies, and quantities of medications prescribed or dispensed is present.
Tests for Follow-Up 10.0% A complete list of any pathology, cultures, radiology, or other diagnostic tests still pending and who is responsible for follow-up on final results is present.
Listing of Discharge Follow-Ups 10.0% A complete list of discharge therapies, treatments, referrals, consults, and follow-up appointments is present.
Organization and Effectiveness 20.0%
Mechanics of Writing (includes spelling, punctuation, grammar, language use) 20.0% Writer is clearly in command of standard, written, academic English.
Format 10.0%
Paper Format (Use of appropriate style for the major and assignment) 5.0% All format elements are correct.
Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style) 5.0% Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.
Total Weightage 100%