general

GENERAL DISCHARGE

All lab work, imaging and diagnostic studies were reviewed by me. The patient was counseled extensively on my clinical impression, diagnosis, expected course of the disease, and plan, including their follow-up care. The patient agreed to call their primary care physician immediately for a follow up appointment. The patient was given the opportunity to ask questions and all questions were answered by myself and the nursing staff. The patient verbally expressed understanding of the discharge instructions, including the reasons to return to the Emergency Department.

TIMING

The times in the chart may not be reflective of actual patient care times, interventions, or procedures. Documentation occurs after the physical care of the patient.

The patient has requested to leave the ED against medical advice. The patient reason(s) for leaving include, but are not limited to, the following: XXXX. I believe this patient is of sound mind and competent to refuse medical care. The patient is responding and asking questions appropriately. The patient is oriented to person, place and time. The patient is not psychotic, delusional, suicidal, homicidal or hallucinating. The patient demonstrates a normal mental capacity to make decisions regarding their healthcare. The patient is clinically sober and does not appear to be under the influence of any illicit drugs at this time. The patient has been advised of the risks, in layman terms, of leaving AMA which include, but are not limited to death, coma, permanent disability, loss of current lifestyle, delay in diagnosis. Alternatives have been offered - the patient remains steadfast in their wish to leave. The patient has been advised that should they change their mind they are welcome to return to this hospital, or any other, at any time. The patient understands that in no way does an AMA discharge mean that I do not want them to have the best medical care available. To this end, I have provided appropriate prescriptions, referrals, and discharge instructions. The patient ***did/did not*** sign AMA paperwork. The above discussion was witnessed by another member of staff.

Due to patients current smoking history I had an extensive discussion lasting more than 3 minutes about the need to quit smoking.

INTOXICATION DISCHARGE

The patient is clinically sober. The patient is alert and oriented x 3, is clear and coherent in conversation and has a normal gait and shows no signs of acute intoxication. The patient is safe for discharge.

OPIOID DISCHARGE

Will discharge patient with a short course of opiates. Went over the risks of the medication. Advised patient to not mix with other products containing acetaminophen, to not combine with alcohol, or other illicit drugs, to not drive or operate machinery, and to refrain from any activity that will require complete attention while taking this medication.

DRUG SEEKING

The patient is manifesting multiple drug seeking attributes. Prior medical records, if available, were reviewed. Discussed with the patient that opioid pain medication will not be given during the ED visit. Alternative analgesia is offered and REFUSED/ACCEPTED.

The patient was signed out to the incoming physician. All decisions regarding the progression of care and interpretation of tests will be made at their discretion.

Patient was counseled to not drive, operate heavy machinery and/or make important decisions while on taking prescribed medications. The patient expresses understanding that these medications can impair their judgment.