Headings
Admission summary · Discharge diagnoses · Medication reconciliation · Pending results · Follow-up appointments · Services arranged · Plan
When to use it
Use this for the first office visit after a hospital or skilled nursing stay, usually within 7 to 14 days of discharge. It reconciles the discharge summary with what the patient is actually taking and chases pending results and arranged services. That makes it different from a routine follow-up, where there is no admission to close out.
Example
Fictional example
Admission summary
H.J., 76. Admitted 4 days for heart failure exacerbation. Diuresed 9 lb. Discharged 5 days ago.
Discharge diagnoses
Acute on chronic heart failure with reduced ejection fraction, EF 35 percent. Hypokalemia.
Medication reconciliation
Furosemide increased to 40 mg twice daily. Potassium chloride 20 mEq daily added. Patient still taking old furosemide 20 mg bottle too. Corrected today.
Pending results
Echocardiogram report not yet received. Potassium 3.6 on discharge.
Follow-up appointments
Cardiology in 3 weeks, confirmed.
Services arranged
Home health nursing twice weekly. Scale delivered.
Plan
Daily weights, call if up 3 lb in a day. Basic metabolic panel in 3 days. Discard old furosemide bottle.