social work discharge summary example

Her fall was not observed, but the patient does not profess any loss of consciousness, recalling the entire event. HISTORY OF PRESENT ILLNESS: This (XX)-year-old Hispanic female was admitted for fever, hypotension and back and right shoulder pain after a fall at the nursing home. History of recurrent urinary tract infection. This brief three-sentence summary showcases your relevant qualifications. The information in this post will serve as a simple template for organizing your case information and ensuring that all relevant details are present in your summary. 5. FOBT x3 were done and cardiology followup as outpatient. Atrial fibrillation with subtherapeutic INR. She was started on food. No further workup was warranted by cardiology other than echo at this time. History of chronic obstructive pulmonary disease. No drugs. EXTREMITIES: Upper and lower limbs bilaterally normal. CT chest, abdomen, and pelvis were done. 4. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. 6. This is different from the discharge instructions you give to patients which includes symptoms and signs to report or seek care for (e.g. thrice daily, digoxin 0.125 mg p.o. ACTIVITY: Per physical therapy and rehabilitation. Hospital, College of Public Health & Health Professions, Clinical and Translational Science Institute, A Pandemic within a Pandemic — Intimate Partner Violence during Covid-19, The Discovery of Hepatitis C — The 2020 Nobel Prize in Physiology or Medicine, Durability of Responses after SARS-CoV-2 mRNA-1273 Vaccination, Pembrolizumab in Microsatellite-Instability–High Advanced Colorectal Cancer. She was set up with a skilled nursing facility, which took several days to arrange, where she was to be given daily physical therapy and rehabilitation until appropriate for her previous residence. Deep venous thrombosis. daily. Activity-practice discharge summary example completion. The discharge summary is often seen as the bane of any intern’s existence. The patient has had similar episodes since one year. She gets Dilaudid 0.2 mg IV p.r.n. Reading the example of your case notes, I believe it would be helpful. Medications at Home: Zestril 40 mg p.o. *These categories are not necessary on off-service notes. Initial x-ray showed possible fracture. The information was provided by nursing facility staff who have successfully discharged Medicaid residents to the community; however, the names and details of the cases have been changed to protect confidentiality. 4. PHYSICAL EXAMINATION: The patient appears cushingoid. We’ve created the social worker resume examples you see below to help you write a better resume in less time. means and could you provide an example. For example, under hospice care, social workers are required by law to be part of an "interdisciplinary group." Family therapy conducted by social work department with the patient and the patient's family for the purpose of education and discharge planning. 5. As a summary template, all information is written in brief and concise points. CONSULTS OBTAINED: A rehab consult was done. No colonoscopy done. DISCHARGE DIAGNOSES: 2. Sample resumes in this field indicate duties such as working with doctors, nurses and support staff to determine the safest discharge plan for the patient; and communicating with outside agencies to make referrals for post acute care. That was continued. She has a jejunostomy. Liver enzymes drawn were within normal limits. GENITOURINARY: Prostate is hypertrophic with smooth margin. Montana State Hospital Forensic Mental Health Facility Policy and Procedure DISCHARGE SUMMARY FOR THE FORENSIC MENTAL HEALTH FACILITY Page 2 of 3 3. 8. 5. Discharge Planner II Resume. Bilateral Reduction Mammoplasty Surgery Sample Report. But on day 4 he developed diarrhea so we added flagyl to cover for c.diff, which did come back positive on day 6 so he needs 3 more days of that…” this can be summarized more concisely as follows: “Completed 5 day course of azithromycin for pan sensitive strep pneumoniae pneumonia complicated by c.diff colitis. b.i.d. HEART: Irregular rhythm. It will also include an intended care planfor the patient after he or she is discharged from the facility. That's not incompetent, but it won’t release a flood of interviews. Like the social work CV sample, you can mention your achievements, specialties, and related experience. ABSTRACT Our work explores a brief historical development on discharge planning in hospitals and examines its significance in medical social work by considering the role of the hospital social worker. 8. What does a good social work CV look like? Example clinical notes to accompany the discharge summary writing task, in PDF format for ease of printing, if desired. Currently on day 7/10 of flagyl and c.diff negative on 9/21.”. and p.r.n. DISCHARGE MEDICATIONS: The patient was discharged on the following medications; Cardizem 90 mg p.o. Social Worker Job Seeking Tips. These cookies will be stored in your browser only with your consent. His folate was 18.7 and his TSH was 1.98, free T4 of 1.38 and T4 level of 7.4, cortisol level of 15.4, which are within normal limits. Social Worker 1 TITLE: Social Worker REPORTS TO: Director of Social Services FLSA STATUS: Non-Exempt / 0.5 - 1.0 FTE SUMMARY: The hospice Social Worker furthers the mission of hospice by providing clinical support to patients and their families in conjunction with the other members of the hospice team. 4. She was continued on Claforan, Flagyl and Diflucan. GP Practice Identifier –a national code which i… BRIEF HISTORY:  The patient is an (XX)-year-old female with history of previous stroke; hypertension; COPD, stable; renal carcinoma; presenting after a fall and possible syncope. She will continue with blood sugar control. The patient underwent an AKA by Dr. Doe without significant complications. 1. The patient will follow up with Dr. Doe for medication management and Dr. Smith for psychotherapy. Course of Treatment, 3. She has finished HBO at this time. Medical Transcription Discharge Summary Sample # 1: 1. Prophylaxis. (e.g. The patient’s fever resolved. Developed relationships and built rapport with a caseload of 10 weekly clients using active listening and client centered counseling techniques. 3. Hydrocortisone was discontinued and she was put on prednisone. You have spent days, sometimes weeks, providing care for a patient and now it all needs to be summarized in a brief document. Initial examination showed tachycardia of 128, rest tachypnea of about 35-40, inspiratory and expiratory wheezes and rhonchi on lung examination. By using this site, you agree to the use of cookies. 6. Mild confusion. DATE OF DISCHARGE: MM/DD/YYYY 5. What do S.O.A.P. This will not be included on transfer summaries or off-service notes. I would recommend followup x-ray in one month of the right mandibular area to ensure this is unchanged. “Patient to arrange appointment time to be seen within two weeks.”). Short bowel syndrome. She has been having problems with short bowel syndrome because essentially the whole ileum has been removed. p.r.n., clonidine 0.1 mg p.o. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 188/74, pulse 62, respirations 18 and saturation of 98% on room air. and Colace 100 mg p.o. 1. On MM/DD/YYYY, hemoglobin was 10.8. Hospital Social Workers counsel patients and provide support in finding resources for their care. No focal weakness, headache, vision changes or speech changes. History of renal carcinoma, stable. 2. The patient is on tigecycline 50 mg q.12 h., Coumadin 5 mg at bedtime, Pentasa 1 gram p.o. The role of the hospital social worker in Pending Studies: List all studies that are outstanding and to whom the results will be sent in the case of discharges. Client, or parent/guardian, no longer wants CCS Services. The patient at home was on Digitalis. Last blood pressure on MM/DD/YYYY was 94/50. The patient also had a head CT which showed atrophy with old ischemic changes. Follow up per skilled nursing facility until discharged to regular residence. Example clinical notes with accompanying blank discharge summary, with relevant fields pre-populated. On MM/DD/YYYY, chest x-ray showed satisfactory PICC position. Peripheral arterial disease with hypertension, peripheral neuropathy, atherosclerosis, hemorrhoids, proctitis, CABG, and cholecystectomy. CT chest had an impression of coronary artery calcification, aortic valve replacement, cardiomegaly, suspect a very small left pleural effusion, no acute active pulmonary disease. She was put on prednisone. DATE OF ADMISSION: MM/DD/YYYY. She was seen by Dr. Doe who recommended TobraDex t.i.d. Summary : Seeking to utilize the abilities developed through education and having the capability to search for a solution and solving the problem.To pursue a challenging career and be part of a progressive organization that gives me an opportunity to enhance the professional skills and work with a diverse group of people for the ultimate goal of organizational growth. Alcohol socially. Psychiatric Discharge Summary Sample Report #2. Traumatic arthritis, right knee. Self-limited electrolyte abnormalities, minor medication adjustments, routine fluid administration are too detailed. The patient was put on IV heparin because of ultrasound of the upper extremity showing deep venous thrombosis in the cephalic vein on the right. Status post fall with trauma: The patient was unable to walk normally secondary to traumatic injury of her knee, causing significant pain and swelling. I still recommend a followup right mandibular x-ray in 3 to 4 weeks to ensure there are no changes and this definitely was the patient’s bridge. For patients who are followed for ongoing and continuous social work services such as our automatic referrals to Rehab, ICU, and Hem/Oncology, the minimum requirement is a once per week summary inpatient progress note. 5. The patient was on allopurinol. This website uses cookies to improve your experience. Activity-practice discharge summary writing task. It is mandatory to procure user consent prior to running these cookies on your website. As stated, family therapy was conducted. The patient also complains of weight loss of 25 pounds in the last 6 months. She continued on hemodialysis. daily, and Macrobid for prophylaxis, 100 mg p.o. The patient is discharged to skilled nursing facility at this time. Discharge Diagnosis*: Make sure this is a diagnosis and not a symptom or sign. Bowel sounds are positive. 2. 6. If the patient is to schedule the appointment, then make sure you include the time frame by which the patient should schedule the appointment. The patient is alert, awake, and oriented x3. A 2D echocardiogram with left ventricular hypertrophy, inferior septal hypokinesis and mildly impaired left ventricular function, sclerotic aortic valve, moderate mitral and severe tricuspid insufficiency. Recent history of hematochezia but believes it was secondary to proctitis and secondary to decreased appetite. Physical and occupational therapy was ordered, but the patient could not tolerate it because of abdominal pain. She will follow with renovascular surgery, ID, cardiology and skilled nursing facility MD once discharged. HEENT: Conjunctivae are normal. 1. Include a 24/7 call-back number. Lower extremity Doppler negative for deep venous thrombosis. Medical Transcription Discharge Summary Sample Report # 3. Effective, efficient, and compassionate discharge planning can benefit patients as well as hospitals and mental health facilities in a multitude of ways. FINAL DIAGNOSES: The patient was admitted for evaluation of her fall and to rule out syncope and possible stroke with her positive histories. Sodium 133, potassium 4.7, chloride 104. At CCMH, created 27 treatment plans and worked with … The legal context of social work is important because it provides duties and powers for social work and it provides an understanding of the statutory and legal requirements for effective and fair social work practice (Brammer, 2010). The patient is FULL CODE. Hypertension. 3. The patient was seen by the pain management service. q.4-6 h. p.r.n. INITIAL PSYCHIATRIC ASSESSMENT 3/12/2012 Complete Evaluation History: Anna is a divorced Canadian 59 year old woman. Before discharge, she received asthma education and social counseling along with the family and was connected with social work to help provide a home nebulizer for use. 3 tablets so a total of 90 mg q.a.m., citalopram 10 mg q.a.m., fluconazole 200 mg daily, azathioprine 100 mg daily, metoprolol 50 mg b.i.d. 6. daily, Norvasc 5 mg p.o. and she is on Ambien 10 mg at bedtime for sleep. A discharge summary is to be entered into the patient record within fifteen (15) days ... medical, social, work, marital/children, military service, and criminal histories, and living situation. 3. 5. 1. “walking w/ walker”; “stable but confused and requires assistance w/ ADLs”). HOSPITAL COURSE: Echocardiogram showed normal left ventricular function, ejection fraction estimated greater than 65%. Imuran was held. This website uses cookies to improve your experience while you navigate through the website. The impression was atrophy with old ischemic changes but no acute intracranial findings. hold for systolic blood pressure less than 120, Lomotil 2 tabs q.6 h., prednisone 5 mg daily. Before discharge, she received asthma education and social counseling along with the family and was connected with social work to help provide a home nebulizer for use. Summary of Qualifications. Discharge Status and Instructions _____ _____ 1. X-ray of the left knee showed mild degenerative changes. PLAN: Transfer the patient to an expert in short bowel syndrome. multidimensional information on the client and his or her situation is gathered and assessed End-stage renal disease. On MM/DD/YYYY, hemoglobin was 9.2. No acute intracranial findings. daily, Plavix 75 mg p.o. BRIEF HISTORY: The patient is a (XX)-year-old white female with known history of asthma since infancy, possible environmental allergies, who presented with progressive wheezing and respiratory distress for the past two days. When specialization occurred, it was related to the populations served and not the specialized tasks or methods utilized. Urine C&S showed no growth. Significant medical and/or physical … Blood cultures x2 showed no growth. LUNGS: Clear to auscultation and percussion bilaterally. The patient was complaining of pain in her hand. q.h.s., and Remeron 15 mg p.o. The patient was referred for admission for evaluation of worsening asthma and possible pneumonia. Discharge Summary Medical Transcription Sample Reports. Initial Assessment 2. The patient continued on IV antibiotics and wound care. Discharge summary is a document that contain a simple summary of the patient’s health information and their time at the hospital or facility. The patient was able to reach the books, to support self, but did not have any syncope. SAMPLE Page 1 of 3 Printed by: Snow, Mike on 15-OCT-2015 GENERAL INTERNAL MEDICINE DISCHARGE SUMMARY Patient Name: Smith, John MRN: 1234567 DOB: 25-Dec-1950, 65 years old Gender: Male VISIT ENCOUNTER Visit Number: 11186424686 Admission Date: 08-Oct-2015 Discharge Date: 14-Oct-2015 Discharge Diagnosis: Pyelonephritis Primary Care Provider / Family Physician: Jay, … Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. (e.g. Creatinine was down to 1.2. She was given IV Dilaudid as needed. She was started back on Plavix and Coumadin was not restarted. The patient was transferred out of the intensive care unit. The patient’s INR was well controlled on Coumadin, so the heparin has been discontinued. Instead, emulate our next human services resumes example: Social Worker Resume Summary . Dr. Doe had scoped the jejunum and found copious mucus and mild colitis. daily, hydrochlorothiazide 50 mg p.o. The patient was started on a taper of hydrocortisone. She has Crohn’s disease. and Flovent 110 mcg 2 puffs b.i.d. Syncope. Attempt to drain the abdominal cavity revealed no drainage. He suggested PT evaluation and suggested a low dose of SSRI and Dr. Doe was of the opinion that the patient does not need any further cardiac recommendation. The patient had a repeat lower extremity Doppler which did not reveal DVT, anticoagulation was discontinued at that time. No thyromegaly. The patient continues to have abdominal pain requiring IV fluids because of the large jejunostomy output. Social worker CV example The above example of an experienced social worker CV, showcases this candidate’s career history and how they have progressed within their career. Page 1A of 7 PSYCHIATRIC CLINIC, LLC 123 Main Street Anywhere, US 12345-6789 555-678-9100 (O) 555-678-9111 (F) DATE ADMITTED : 4/24/2017 DATE DISCHARGED : 7/20/2017 This discharge summary consists of 1. SW/DCP assists in the early identification and assessment of patient’s needs, through high risk screening and psychosocial assessments. No shortness of breath. Together we teach. Recommendations: Include any consults or studies, Follow-up*: Name of doctor, specialty, and appointment location and time. Discharge Diagnosis*: Make sure this is a diagnosis and not a symptom or sign. PAST MEDICAL/SURGICAL HISTORY: Positive for atrial fibrillation. Sample Post-Discharge Phone Call Documentation – HIPAA Compliant, Medicine Seminar/Well-Being Rounds/Doc-in-the-Box Schedules, Comprehensive Observed Physical Exam Form, Discharge Summary/Transfer Note/Off-Service Note Instructions, Primer to the Internal Medicine Clerkship, Tips for Using Your Myers Briggs Personality Type to Optimize Your Performance in the Clinical Years, Cutaneous Manifestations of Systemic Disease, Foolproof Five Step Approach to Acid-Base, Medicine Clerkship Formative Evaluation Form, Medicine Clerkship Summative Evaluation Form, UF Health Shands Children's There was an area seen on the right shoulder x-ray, in the right parotid region, which appeared calcified; however, the patient does wear a bridge and had it on at the time of the x-ray, most likely representing these findings. MEDICATIONS: Zithromax for two remaining days, albuterol one dose nebulizer treatment q.i.d. In the hospital, the patient’s warfarin was increased to 5 mg q.h.s., and at the time of the discharge, he was requested to follow his appointments so that his INR can be maintained. “home with home health”, “daughter’s house”, “Shands rehab”, “ 8th floor, Psychiatry service”), Discharge Medications: List all medications the patient needs to take at home including doses, route, frequency and date of last dose when applicable. As a social worker, you’ll be working not just to make money but to improve the quality of people’s lives. On MM/DD/YYYY, white count was 4600, hemoglobin 10.2, INR 2.18. HOSPITAL COURSE: The patient responded well to individual and group psychotherapy, milieu therapy and medication management. Family members would need to understand the condition of their family member and how they could successfully relate to him or her. Resumes for this position highlight such responsibilities as facilitating discharge planning to appropriate levels of care from acute care settings, interfacing with community liaisons and insurance case managers to expedite discharge, and engaging in multidisciplinary team meetings. STUDIES: The admission chest x-ray showed clear lungs. Together we care for our patients and our communities. This section should be completed with the details of the General Practitioner with whom the patient is registered: 1. Any serious conditions were quickly ruled out. Came to ER and had a CT head, which was within normal limits. Status asthmaticus. Fibromyalgia. No acute intracranial findings. 2. No nausea, vomiting, no abdominal pain. The patient had a chest x-ray, which showed cardiomegaly with atherosclerotic heart disease, pleural thickening and small pleural effusion, a left costophrenic angle which has not changed when compared to prior examination, COPD pattern. HOSPITAL COURSE: The patient was initially admitted with right lower extremity calf thrombosis and cellulitis of the right calf. The regulations spell out in more detail the role of the interdisciplinary group. Hypertension. 1. Discharge Summary/Transfer Note/Off-Service Note Instructions. The patient was ruled out of any malignancy whatsoever. Status asthmaticus: The patient was admitted to the pediatric intensive care unit in moderate to severe respiratory distress with continuous albuterol treatments, Atrovent treatments q.4 h., Decadron intravenously and empiric treatment of respiratory infection with azithromycin intravenously. Imuran was restarted. 12 years of Extensive Experience providing Clinical Social work. Clean catch urine culture showed only mixed skin flora. The patient had AVR 6 years ago. DIAGNOSTIC STUDIES:  All x-rays including left foot, right knee, left shoulder and cervical spine showed no acute fractures. Social Worker Resume Examples. Empiric respiratory infection treatment: The patient did not show any specific indications of pneumonia or bronchitis by lab work; however, her initial physical examination showed possible pneumonia. In essence, discharge summary templates are documents (usually printed) that contain all the health information pertaining to the patient’s stay at a hospital or healthcare facility. For example, instead of “he appeared to have pneumonia at the time of admission so we empirically covered him for community-acquired pneumonia with ceftriaxone and azithromycin until day 2 when his blood cultures grew out strep pneumoniae that was pan sensitive so we stopped the ceftriaxone and completed a 5 day course of azithromycin. You also have the option to opt-out of these cookies. Blood urea nitrogen of 18 and creatinine of 1.1. Sound experience with renal patients and the ability to develop relationships with clients without becoming too emotionally involved. The jejunum was normal to 40 cm. The results revealed that the tasks performed typically resembled that of generalist social workers. 2. 1. SOCIAL HISTORY: Never smoked. From this data recommendations are made for linking advanced generalist social work practice to discharge planning activities. 2. On MM/DD/YYYY, renal ultrasound was negative. Fall: The patient was admitted and ruled out for syncopal episode. Hypotension. No nausea or vomiting. Account manager Social Worker Built trusted relationships with industry leaders, clients and team members. Depression. Course in Treatment 3. Vitamin B12, TSH, free T4 and T3 were ordered along with cortisol level in the morning. CT showed no fracture. Discharge: Client achieved discharge criteria in Recovery Plan. Electrolytes were normal. Date of Admission/Transfer: Date of Discharge/Transfer: Admitting Diagnosis: This should be your working diagnosis at the time of admission (not the chief complaint/presenting symptoms). Medical Transcription Discharge Summary Sample # 2: HISTORY OF PRESENT ILLNESS: This is an (XX)-year-old male with a past medical history of coronary artery disease, CABG done a few years ago, atrial fibrillation, peripheral arterial disease, peripheral neuropathy, recently retired one year ago secondary to leg pain. Dr. Doe was of the opinion that the patient himself takes care of the Coumadin, and Dr. Doe was of the opinion that probably that is why the patient is not able to maintain therapeutic INR. Chest x-ray showed satisfactory PICC position. MEDICATIONS: Darvocet-N 100 one tablet p.o. DISCHARGE INSTRUCTIONS: Since the patient had generalized deconditioning, the patient was advised home PT, OT and that was arranged for the patient. INITIAL … Very effective communication skills. She will be on dicyclomine 20 mg q.6 h., tizanidine 4 mg b.i.d., lidocaine patch to the lower back and left shoulder 12 hours on and 12 hours off, Wellbutrin XR 150 mg 2 tablets daily, trazodone 50 mg b.i.d., Cymbalta 30 mg q.a.m. Hemodialysis. On MM/DD/YYYY, stool for Clostridium difficile was negative. 7. She was seen by Psychiatry. This body is responsible for the development and review of individual treatment plans and the establishment of policies governing the operation of the individual hospice. She was put back on IV fluids. 3. 2. CT of the maxillofacial area showed no facial bone fracture. for 1 week. 1. Hemoglobin was 10.2. EOMI. Dr. Doe saw the patient and advised the same. once daily, allopurinol 100 mg two times daily, Coumadin 4 mg p.o. 2. Initial examination showed bruising around the left eye, normal lung examination, normal heart examination, normal neurologic function with a baseline decreased mobility of her left arm. Necessary cookies are absolutely essential for the website to function properly. The Initial Assessment, 2. Abscess fungal culture was negative on MM/DD/YYYY and MM/DD/YYYY. The job application asks to demonstrate excellent case management writing skills. This category only includes cookies that ensures basic functionalities and security features of the website. The left shoulder did show old healed left humeral head and neck fracture with baseline anterior dislocation. She will continue with hemodialysis as an outpatient. She has had physical therapy and recovered completely from that. Together we discover. X-ray of the right knee showed small bony density along the articular surface of the proximal anterior tibia and mild degenerative changes. Amlodipine was discontinued, metoprolol was decreased. No nystagmus. Medical Transcription Discharge Summary Sample Report # 5: PROCEDURES: Discharge Instructions*: Be specific about activity level, diet, wound care, or others issues the patient’s doctor needs to know. Temperature was as high as 102.4. A good way to think about this is it is basically the same thing you would write as your 1-2 sentence summary statement under the assessment before you go into more details of your thought processes, differential, and plan. The patient was seen by renovascular surgery and infectious disease. q.i.d., Protonix 40 mg daily, Colestid 1 gram b.i.d., Lactinex 2 tabs b.i.d. CT of the brain showed no acute changes, left periorbital soft tissue swelling. If you have changed any of the patient’s admission medications this should be noted along with the rationale. This will not be included on transfer summaries or off-service notes.

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