A nurse developed the following discharge summary sheet. Which critical information should be added?
TOPIC DISCHARGE SUMMARY
Medication
Diet
Activity level
Follow-up care
Wound care
Phone numbers
When to call the doctor
Time of discharge
a. Kardex form
b. Admission nursing history
c. Mode of transportation
d. SOAP notes
ANS: C
List actual time of discharge, mode of transportation, and who accompanied the patient for discharge summary information. In some settings, a Kardex, a portable "flip-over" file or notebook, is kept at the nurses' station. A Kardex is for nurses, not for patients to take upon discharge. A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style.
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