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Rehab Discharge Summary Transcription Example

DISCHARGE DIAGNOSES:
1. Fracture of left inferior pubic ramus.
2. Nondisplaced fracture of the anterior column of the left acetabulum.
3. Osteoarthritis.
4. Hypertension.
5. Urinary tract infection.
6. History of transient ischemic attack.
7. History of right total knee replacement.
8. History of peptic ulcer disease.
9. Hyperlipidemia.

HOSPITAL COURSE: This is a (XX)-year-old female with multiple medical problems who was admitted after falling and landing on her left hip. She did not have loss of consciousness. She was found to have fractures of her left inferior pubic ramus and her pubic bone and nondisplaced fracture of the anterior column of the left acetabulum. She was seen by Dr. Doe, Orthopedics, who felt that this fracture would be best dealt with nonsurgically. She was discharged to this facility for comprehensive inpatient rehabilitation.
1. Rehabilitation: She was nonweightbearing in the left lower extremity during her stay here. She should be nonweightbearing on the left lower extremity for three weeks, then she can be weightbearing as tolerated on that left lower extremity. She has followed up with Dr. Doe for her fracture. Her functional independence measures on admission were modified independence for feeding and grooming, mod assistance for bathing, dressing, and toileting. On discharge, she was modified independence for feeding, supervision for grooming, and min assist to supervision for dressing, bathing, and toileting. On admission, her bowel and bladder scores were total assist for bladder because she had a Foley; this was min assist on discharge. For bowel, she was min assist on admission and min assist on discharge. Mobility: She was min assist with bed/chair, wheelchair, and total assist with toilet, tub, and shower. On discharge, she was min assist with all these tasks. Locomotion: She was total assist on walking and total assist on discharge as well secondary to her weightbearing status. For wheelchair, she was total assist on admission and modified independence on discharge. Comprehension and Expression: She was supervision to modified independence on admission and this was unchanged on discharge. Social Interaction: She was min assist for problem solving and memory and modified independent for social interaction. This was relatively unchanged at min assist to supervision on discharge.
2. DVT prevention: She was on Fragmin here and should continue Fragmin at the skilled nursing facility for prevention of DVTs, until she is ambulatory.
3. Respiratory: She did have some crackles on her lung examination from time to time. Her chest x-ray done here was negative.
4. GU: She came here on a Foley. This was discontinued a week ago without problems.
5. Neurologic: She did have a history of transient ischemic attack one week prior to this fall. Apparently, she had a carotid study that showed moderate bilateral internal carotid artery stenosis. She was started on Plavix. This should be monitored secondary to her history of peptic ulcer disease, and she should continue on Prevacid for GI prophylaxis. She also has decreased hearing acuity and has hearing aids but does not like to wear them.
6. GI: As above.
7. ID: She received a flu vaccine.

DISCHARGE MEDICATIONS: Folic acid 1 mg daily, K-Dur 20 mEq daily, thiamine 100 mg daily, Dulcolax suppository p.r.n., Metamucil one packet b.i.d., Colace 100 mg b.i.d., Os-Cal 500 mg t.i.d., Fosamax 70 mg every Saturday, nitroglycerin 0.4 mg sublingual p.r.n., Fragmin 5000 units subcutaneously daily, Zocor 40 mg q.h.s., spironolactone 25 mg daily, Prevacid 15 mg b.i.d., trazodone 50 mg q.h.s. p.r.n., Detrol LA 2 mg daily, and Plavix 75 mg daily.

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