Documenting a visit after a hospital stay

A: When a patient stays in the hospital for more than 48 hours and is discharged, even if a transfer to another facility is involved, your note should recapitulate the reason for the hospitalization and include significant findings; the procedures or treatments given; and the principal, secondary, and final diagnosis(es). Do not use symptoms unless specified as undiagnosed, but include the patient's discharge status as well as specific instructions to the patient and/or family.

ADMISSION AND DISCHARGE

When a patient is readmitted after a procedure in another facility 2 days later, document this in an admission note in the patient's medical record within 12 hours, if possible. The admission note should contain the reason for admission; provisional diagnosis(es); and a statement regarding the initial assessments of the patient that includes candidacy for a surgical procedure, where appropriate, or any other procedure that involves a degree of risk. The admission note also should have a relevant H&P.

HISTORY AND PHYSICAL

A complete H&P for inpatient admissions and procedures performed in an operat-ing room should include identification data; chief complaint; details of present illness, including an assessment of the patient's relevant medical/social/family history; a review of the inventory of body systems; physical examination; mental status; current medications; allergies; vital signs; and a diagnosis or problem list with a plan of care.

An H&P for children and adolescents should include an evaluation of developmental age; consideration of educational needs and daily activities as appropriate; a parent's report or other documentation of immunization status; family/guardian expectations for and involvement in the assessment, treatment, and care of the patient; and the psychosocial needs as appropriate to the patient's age. This may be part of the H&P or the initial nursing assessment.

Some hospital bylaws state that if you performed an H&P within 30 days before the patient's admission, you may include a copy of the report in the patient's medical record provided you add a note stating that no changes occurred or detailing any changes that occurred. If your hospital's bylaws do not include this information, seek clarification at the hospital's medical staff office.