BWNY - Discharge Summary

60 Niagara Street, 2nd Floor, Buffalo, NY 14202 Phone: (716) 268-8705 Fax: (716) 589-2290

DISCHARGE SUMMARY

Physician: Phone:

Client aware of DC in their preferred method of communication: Yes

Date:

N/A

DC planning note in HHAE which includes client/family aware of DC: Yes

Date:

N/A

Date MD notified of DC:

Client : D.O.B.:

S.O.C : DC Date:

Last Date of Service:

Client Diagnosis:

Dear:

Thank you, for your confidence in our agency. The following is a summary of information regarding your client. We look forward to serving your clients in the future.

Summary of condition upon admission:

Summary of treatment received:

Summary of condition at discharge:

Reason for discharge:

No further care necessary
Hospitalized
Moved out of area
Admitted to nursing home
Expired
Physicians order
Denied by payment source
Transferred
Change of payor
Client/ Family refused care
Client/family request
Request of MLTC
Other

Condition at Discharge:

Optimum function achieved
Optimum function partially achieved
Progress plateaued
Condition deteriorated
Expired
Other

Were the goals of care met?   Yes No NA Comment

Client/family able to manage remaining needs?   Yes No Comment

Recommendations and referral for follow up care, if needed Comment
Education provided as needed Comment
Managed by MLTC
Physician follow up  None needed
Other

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