creates potential for confusion and loss of faith in the system and team SURGICAL A diagnosis but no Further investigations Teach the learner how to CONSULTATION recommendations Improper follow-up incorporate continuing REPORT Inaccurate expectations professional development around recovery process into consultation letters Missed opportunity to (e.g. include relevant educate the physician references, summary of clinical practice guidelines; incorporate education paragraphs about specific treatment, etc.) DISCHARGE Lack of a discharge plan, Patient safety is Tell the learner that it is SUMMARIES with far too much focus compromised critical to summarize on the details of what Confusion and frustration major medical and transpired and little for the primary care surgical issues that information on the next physician and community transpired during the steps and who is services providing course of admission it — responsible for following is easier to review the up on the issues Delay in needed services details if they are identified organized in a format Delay in discharge note that can be readily scanned (numbered list of issues, with descriptions) Explain that the discharge plan must be detailed enough to include the next steps post-discharge, who will do what, and what the patient has been told if the discharge plan isn’t successful. Specifically, the discharge summary needs to clearly identify the expectations of the primary care provider Provide clear guidelines for the completion and delivery of discharge notes
creates potential for confusion and loss of faith in the system and team SURGICAL CONSULTATION REPORT A diagnosis but no recommendations Further investigations Improper follow-up Inaccurate expectations around recovery process Missed opportunity to educate the physician Teach the learner how to incorporate continuing professional development into consultation letters (e.g. include relevant references, summary of clinical practice guidelines; incorporate education paragraphs about specific treatment, etc.) DISCHARGE SUMMARIES Lack of a discharge plan, with far too much focus on the details of what transpired and little information on the next steps and who is responsible for following up on the issues identified Delay in discharge note Patient safety is compromised Confusion and frustration for the primary care physician and community services providing Delay in needed services Tell the learner that it is critical to summarize major medical and surgical issues that transpired during the course of admission — it is easier to review the details if they are organized in a format that can be readily scanned (numbered list of issues, with descriptions) Explain that the discharge plan must be detailed enough to include the next steps post-discharge, who will do what, and what the patient has been told if the discharge plan isn’t successful. Specifically, the discharge summary needs to clearly identify the expectations of the primary care provider Provide clear guidelines for the completion and delivery of discharge notes
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