Academic Discharge Clinical Summary Note Academic Clinical Discharge Summary Note
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SUBMIT ASSIGNMENTRequires LopesWriteStart Date
Academic Clinical Discharge Summary Note
SEE ALL ATTACHMENTS
SUBMIT ASSIGNMENT
Requires LopesWriteStart Date Feb 17, 2022, 12:00 AM Due DateFeb 23, 2022, 11:59 PM Points 60
Academic clinical discharge summary notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating an evidence-based plans of care.
This assignment uses a template. Refer to the “AGACNP Discharge Summary Template,” located on the Student Success Center page under the AGACNP tab.
Develop an academic clinical discharge summary note based on a hospital patient seen during clinical/practicum. The discharge summary note should include the following:
Rubric Criteria Description
Reason for Admission and Full Diagnosis
5. Target
4.2 points
A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are thorough and include substantial supporting details.
4. Acceptable
3.78 points
A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are present and include supporting details.
3. Approaching
3.36 points
A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are present.
2. Insufficient
2.1 points
A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are incomplete or incorrect.
1. 1: Unsatisfactory
0 points
A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are not included.
List of All Procedures
4.2 points
Criteria Description
List of All Procedures
5. Target
4.2 points
A list of all dates, significant findings, anesthetics, and contrast used during procedures is complete.
4. Acceptable
3.78 points
N/A
3. Approaching
3.36 points
N/A
2. Insufficient
2.1 points
A list of all dates, significant findings, anesthetics, and contrast used during procedures is incomplete.
1. 1: Unsatisfactory
0 points
A list of all dates, significant findings, anesthetics, and contrast used during procedures is not included.
Consults During Hospitalization
4.2 points
Criteria Description
Consults During Hospitalization
5. Target
4.2 points
A complete list of consults during hospitalization, including any providers or services consulted during the stay is complete.
4. Acceptable
3.78 points
N/A
3. Approaching
3.36 points
N/A
2. Insufficient
2.1 points
A list of consults during hospitalization, including any providers or services consulted during the stay, is incomplete.
1. 1: Unsatisfactory
0 points
A complete list of consults during hospitalization, including any providers or services consulted during the stay, is not included.
Condition of Patient at Discharge
4.2 points
Criteria Description
Condition of Patient at Discharge
5. Target
4.2 points
Documentation of a physical exam prior to patient discharge that notes the safety and stability of the patient, in addition to any diagnostic criteria that confirmed the discharge diagnosis, is thorough and includes substantial supporting details.
4. Acceptable
3.78 points
Documentation of a physical exam prior to patient discharge that notes the safety and stability of the patient, in addition to any diagnostic criteria that confirmed the discharge diagnosis, is present and includes supporting details.
3. Approaching
3.36 points
Documentation of a physical exam prior to patient discharge that notes the safety and stability of the patient, in addition to any diagnostic criteria that confirmed the discharge diagnosis, is present.
2. Insufficient
2.1 points
Documentation of a physical exam prior to patient discharge that notes the safety and stability of the patient, in addition to any diagnostic criteria that confirmed the discharge diagnosis, is incomplete or incorrect.
1. 1: Unsatisfactory
0 points
Documentation of a physical exam prior to patient discharge that notes the safety and stability of the patient, in addition to any diagnostic criteria that confirmed the discharge diagnosis, is not included.
Discharge Medications
4.2 points
Criteria Description
Discharge Medications
5. Target
4.2 points
A full list of discharge medications that includes all dosages, frequencies, and quantities of medications prescribed or dispensed is complete.
4. Acceptable
3.78 points
N/A
3. Approaching
3.36 points
N/A
2. Insufficient
2.1 points
A list of discharge medications that includes all dosages, frequencies, and quantities of medications prescribed or dispensed is incomplete.
1. 1: Unsatisfactory
0 points
A full list of discharge medications that includes all dosages, frequencies, and quantities of medications prescribed or dispensed is not included.
Pending Test Results for Follow-Up
4.2 points
Criteria Description
Pending Test Results for Follow-Up
5. Target
4.2 points
A complete list of any pathology, cultures, radiology, or other diagnostic tests still pending, including an indication of who is responsible for follow-up on final results, is complete.
4. Acceptable
3.78 points
N/A
3. Approaching
3.36 points
N/A
2. Insufficient
2.1 points
A complete list of any pathology, cultures, radiology, or other diagnostic tests still pending, including an indication of who is responsible for follow-up on final results, is incomplete.
1. 1: Unsatisfactory
0 points
A complete list of any pathology, cultures, radiology, or other diagnostic tests still pending, including an indication of who is responsible for follow-up on final results, is not included.
Discharge Instructions
4.2 points
Criteria Description
Discharge Instructions
5. Target
4.2 points
Directions regarding infection prevention, new medications, and returning to daily activities are thorough and include substantial supporting details.
4. Acceptable
3.78 points
N/ADirections regarding infection prevention, new medications, and returning to daily activities are present and include supporting details.
3. Approaching
3.36 points
Directions regarding infection prevention, new medications, and returning to daily activities are present.
2. Insufficient
2.1 points
Directions regarding infection prevention, new medications, and returning to daily activities are incomplete or incorrect.
1. 1: Unsatisfactory
0 points
Directions regarding infection prevention, new medications, and returning to daily activities are not included.
Discharge Follow-Ups
4.2 points
Criteria Description
Discharge Follow-Ups
5. Target
4.2 points
Therapies, treatments, referrals, consults, and follow-up appointments, in addition to any diagnostic criteria needed after discharge, are thorough and include substantial supporting details.
4. Acceptable
3.78 points
Therapies, treatments, referrals, consults, and follow-up appointments, in addition to any diagnostic criteria needed after discharge, are present and include supporting details.
3. Approaching
3.36 points
Therapies, treatments, referrals, consults, and follow-up appointments, in addition to any diagnostic criteria needed after discharge, are present.
2. Insufficient
2.1 points
Therapies, treatments, referrals, consults, and follow-up appointments, in addition to any diagnostic criteria needed after discharge, are incomplete or incorrect.
1. 1: Unsatisfactory
0 points
Therapies, treatments, referrals, consults, and follow-up appointments, in addition to any diagnostic criteria needed after discharge, are not included.
Summary
4.2 points
Criteria Description
Summary
5. Target
4.2 points
The addressing of questions raised during the hospital stay, in addition to a discussion about questions requiring further exploration, discharge planning, and patient interaction activities, is thorough and includes substantial supporting details.
4. Acceptable
3.78 points
The addressing of questions raised during the hospital stay, in addition to a discussion about questions requiring further exploration, discharge planning, and patient interaction activities, is present and includes supporting details.
3. Approaching
3.36 points
The addressing of questions raised during the hospital stay, in addition to a discussion about questions requiring further exploration, discharge planning, and patient interaction activities, is present.
2. Insufficient
2.1 points
The addressing of questions raised during the hospital stay, in addition to a discussion about questions requiring further exploration, discharge planning, and patient interaction activities, is incomplete or incorrect.
1. 1: Unsatisfactory
0 points
The addressing of questions raised during the hospital stay, in addition to a discussion about questions requiring further exploration, discharge planning, and patient interaction activities, is not included.
Overall Assessment
4.2 points
Criteria Description
Overall Assessment
5. Target
4.2 points
Identification of health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes is thorough and includes substantial supporting details.
4. Acceptable
3.78 points
Identification of health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes is present and includes supporting details.
3. Approaching
3.36 points
Identification of health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes is present.
2. Insufficient
2.1 points
Identification of health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes is incomplete or incorrect.
1. 1: Unsatisfactory
0 points
Identification of health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes is not included.
Mechanics of Writing
6 points
Criteria Description
Includes spelling, capitalization, punctuation, grammar, language use, sentence structure, etc.
5. Target
6 points
No mechanical errors are present. Skilled control of language choice and sentence structure are used throughout.
4. Acceptable
5.4 points
Few mechanical errors are present. Suitable language choice and sentence structure are used.
3. Approaching
4.8 points
Occasional mechanical errors are present. Language choice is generally appropriate. Varied sentence structure is attempted.
2. Insufficient
3 points
Frequent and repetitive mechanical errors are present. Inconsistencies in language choice or sentence structure are recurrent.
1. 1: Unsatisfactory
0 points
Errors in grammar or syntax are pervasive and impede meaning. Incorrect language choice or sentence structure errors are found throughout.
Format/Documentation
12 points
Criteria Description
Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline.
5. Target
12 points
No errors in formatting or documentation are present. Selectivity in the use of direct quotations and synthesis of sources is demonstrated.
4. Acceptable
10.8 points
Appropriate format and documentation are used with only minor errors.
3. Approaching
9.6 points
Appropriate format and documentation are used, although there are some obvious errors.
2. Insufficient
6 points
Appropriate format is attempted, but some elements are missing. Frequent errors in documentation of sources are evident.
1. 1: Unsatisfactory
0 points
Appropriate format is not used. No documentation of sources is provided.
Total 60 points
