Medical Transcription Discharge Summary Sample #1:
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Vasovagal syncope, status post fall.
2. Traumatic arthritis, right knee.
3. Hypertension.
4. History of recurrent urinary tract infection.
5. History of renal carcinoma, stable.
6. History of chronic obstructive pulmonary disease.
CONSULTANTS: None.
PROCEDURES: None.
BRIEF HISTORY: The patient is an (XX)-year-oldfemale with history of previous stroke; hypertension; COPD, stable;renal carcinoma; presenting after a fall and possible syncope.While walking, she accidentally fell to her knees and did hit herhead on the ground, near her left eye. Her fall was not observed,but the patient does not profess any loss of consciousness,recalling the entire event. The patient does have a history ofprevious falls, one of which resulted in a hip fracture. She hashad physical therapy and recovered completely from that. Initialexamination showed bruising around the left eye, normal lungexamination, normal heart examination, normal neurologic functionwith a baseline decreased mobility of her left arm. The patient wasadmitted for evaluation of her fall and to rule out syncope andpossible stroke with her positive histories.
DIAGNOSTIC STUDIES: All x-rays including leftfoot, right knee, left shoulder and cervical spine showed no acutefractures. The left shoulder did show old healed left humeral headand neck fracture with baseline anterior dislocation. CT of thebrain showed no acute changes, left periorbital soft tissueswelling. CT of the maxillofacial area showed no facial bonefracture. Echocardiogram showed normal left ventricular function,ejection fraction estimated greater than 65%.
HOSPITAL COURSE:
1. Fall: The patient was admitted and ruled out for syncopalepisode. Echocardiogram was normal, and when the patient was able,her orthostatic blood pressures were within normal limits. Anyserious conditions were quickly ruled out.
2. Status post fall with trauma: The patient was unable to walknormally secondary to traumatic injury of her knee, causingsignificant pain and swelling. Although a scan showed no acutefractures, the patient’s frail status and previous use of caneprevented her regular abilities. She was set up with a skillednursing facility, which took several days to arrange, where she wasto be given daily physical therapy and rehabilitation untilappropriate for her previous residence.
DISCHARGE DISPOSITION: Discharged to skillednursing facility.
ACTIVITY: Per physical therapy andrehabilitation.
DIET: General cardiac.
MEDICATIONS: Darvocet-N 100 one tablet p.o.q.4-6 h. p.r.n. and Colace 100 mg p.o. b.i.d. Medications at Home:Zestril 40 mg p.o. daily, Plavix 75 mg p.o. daily, Norvasc 5 mgp.o. daily, hydrochlorothiazide 50 mg p.o. daily, potassiumchloride 40 mEq p.o. daily, Atrovent inhaler 2 puffs q.i.d.,albuterol inhaler 2 puffs q.4-6 h. p.r.n., clonidine 0.1 mg p.o.b.i.d., Cardura 2 mg p.o. daily, and Macrobid for prophylaxis, 100mg p.o. daily.
FOLLOWUP:
1. Follow up per skilled nursing facility until discharged toregular residence.
2. Follow up with primary provider within 2-3 weeks on arriving tohome.
list of all applicable diagnoses and assign a code toeach of them. only coding diagnoses; not procedures, medications,etc. Watch for signs and symptoms that are integral to a condition-not code the signs or symptoms when a definitive condition isestablished.
ICD-10 Diagnosis code
