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Discharge Records

The physician's discharge order and follow-up care instructions should also be entered into the medical record. The discharge note should contain any pertinent medical findings and the discharge dictation should be done promptly (see the chapter on medical records). The physician should be careful to record in the medical record, as well as in the patient's office chart, all outpatient prescriptions given the patient. The medical record must reflect the patient's condition at the time of discharge, including the reasons for follow-up care.

There is a temptation to put very little information in the chart at the time of discharge and then put the necessary, more complete information in the dictated discharge summary. While not ideal, this is acceptable if the discharge summary is done at once. Unfortunately, discharge summaries are often put off until weeks or months later. The physician's memory is not fresh at the point, so the discharge summary must be reconstructed from the chart. If all the necessary information is not in the chart, the accuracy of the discharge summary may be questioned. Additionally, if the patient suffers an adverse consequence before the discharge summary is dictated, the discharge summary will be questioned as being self-serving to the extend that it relates exculpatory information not otherwise documented in the chart.


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