I just kept it short and to the point. All micro-details should be in the record already, so no need to repeat them. This is merely a note about your patient's condition At discharge.
Include current status, instructions given (ie: instruction sheet is given, any pt-specific items such as precautions, etc., follow up appt), that your pt or their caretaker verbalized understanding of said instructions, who is taking pt home, and by which method.
Ex: Discharged via w/c to private car with all personal belongings, accompanied by her sister/parent/spouse, etc. In stable condition with VS WNL (or specify acceptable conditions as indicated by the medical provider/team/policy). Able to ambulate independently (or which assistive devices used). Written discharge instructions were given and reviewed, including meds, follow-up appts, and precautions to take at home. Pt (spouse, etc) verbalized understanding of instructions, and all questions were addressed. Cautioned about not driving while taking ____ med, etc (condition-specific), and pt verbalized understanding. **
**This is the format I used "back in the day", and I still remember it! Computer charting can pretty much automate a lot of this, but be sure to ADD Patient SPECIFIC instructions so you can prove that you're not just "boiler-plating" your notes, but are following JCAHO guides in personalizing them to your individual patients' needs.
At my facility, the discharge 'form' was on our computer, and was adaptable to add specific items unique to that pt, in addition to those common with that medical issue. It was pretty much a checklist, highlighting items applicable to your pt., with the ability to add specific meds, appts, precautions, etc, so it was fairly quick to just add specifics to each pt and the majority of "common" instructions/directions were already a part of it. Once this was done, it was saved on the computer, and printed out to hand to our pts.
At the end of the day, ask yourself if someone can come in, never having met your patient, close their eyes, and with what you've written, (or boxes checked) get a "visual" on what their discharge looked like, and if they, in that situation, would have had other questions, not addressed here. The "old" adage remains: CYA!
Even though in todays' times, we are busy beyond belief, short on time and staff, unfortunately, CYA should always be in your mind. I can tell you there were a few times this has literally saved me from people who were trying to get "something for nothing" by making accusations about their encounters. Since my entries were time-stamped by the computer, and specific, they literally had nowhere to go with their fabrications.
Sorry for the length of this, but you really did bring up an important question. Hopefully, with computer charting, it's been pretty much automated to make it go a lot faster, but PLEASE add any important SPECIFICS as needed! It WILL save you at some point, and you'll be Very grateful you did!
