A nurse is preparing a discharge summary. Which item should the nurse include?
a. Provision for follow-up care
b. Patient status at admission
c. Standardized nursing care plan
d. Detailed description of nursing procedures
A
A nursing discharge note needs to cover the reason for hospitalization, procedures performed, care, treatment, and services provided, patient status at discharge, information provided to the patient and family, and provisions for follow-up care. Patient status at discharge, not admission, is included. Standardized nursing care plans are based on the institution's standards of nursing practice and are preprinted established guidelines of care for patients with similar health problems. Detailed descriptions of nursing procedures are located in policy and procedure manuals, but not in a discharge summary.
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