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Follow-up appointments should also be coordinated with the patient prior to discharge to monitor the patient's progress as well as any potential complications that may have arisen. [2] A 2016 Cochrane review showed some benefit to patient health when using individualised discharge planning over a standard format, though no reduction in health ...
The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters. This should address each item of the differential diagnosis. For patients who have multiple health problems that are addressed in the SOAP note, a plan is developed for each problem and is numbered accordingly based on severity and ...
Discharge planning processes can be effective in reducing a patient's length of stay in hospital. For example, for older people admitted with a medical condition, discharge planning has been shown to improve satisfaction, reduce the overall length of stay, and within 3-month period reduce the likelihood of readmission. [ 4 ]
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1]
The nursing care plan (NCP) is a clinical document recording the nursing process, which is a systematic method of planning and providing care to clients. [6] It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriened rather than nursing-process-based. [8]
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Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...
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