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Inpatient Times January 2007Transitions of Care How to Write a Good Discharge Summary By Kimberly Dodd, MD Imagines the scenario Its 12:30 P.M. and you have clinic scheduled in 45 minutes. The case
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01
Start by gathering all necessary patient information, including medical history, current medications, and contact information for healthcare providers.
02
Identify the receiving healthcare facility or provider where the patient will be transitioning to.
03
Ensure that the patient's primary healthcare provider is involved in the transition of care process.
04
Obtain any required consent forms or authorizations for the sharing of medical information.
05
Prepare a comprehensive and organized transition of care summary, including diagnosis, treatment plans, and follow-up care recommendations.
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Coordinate with the receiving healthcare facility to schedule appointments or procedures, if necessary.
07
Communicate with the patient and their family/caregivers to provide them with the necessary information and support during the transition process.
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Ensure that the patient's medications are properly reconciled and that they understand any changes or new medications.
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Facilitate the transfer of medical records and other pertinent documents to the receiving healthcare facility.
10
Follow up with the patient and the receiving healthcare facility to assess the success of the transition and address any concerns or issues.

Who needs transitions of care how?

01
Patients who are transitioning from one healthcare setting to another, such as a hospital to a rehabilitation center or a skilled nursing facility.
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Patients who have complex medical conditions or require multiple healthcare providers and specialists.
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Elderly patients who may have difficulty managing their own healthcare needs.
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Patients who have recently undergone a surgical procedure or had a significant change in their medical condition.
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Patients who are being discharged from a hospital and require ongoing care and support.
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Patients with chronic illnesses or conditions that require regular monitoring and management.
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Patients with a history of medication non-compliance or difficulty following medical instructions.
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Patients who have experienced a recent change in their medication regimen or treatment plan.
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Patients who have recently relocated or had a change in their healthcare insurance provider.
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Transitions of care refer to the movement of patients between different healthcare settings or providers, in a coordinated and comprehensive manner.
Healthcare providers, hospitals, and other healthcare organizations are required to file transitions of care.
Transitions of care forms can be filled out with relevant patient information, medical history, medications, treatment plans, and follow-up care instructions.
The purpose of transitions of care is to ensure continuity of care for patients, reduce medical errors, and improve patient outcomes.
Information such as patient demographics, medical history, medications, treatments, lab results, and care plans must be reported on transitions of care forms.
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