discharge summary
[dɪsˈtʃɑːrdʒ ˈsʌməri]
nounpl: discharge summaries
resumo de alta hospitalar
1. A medical document prepared by a healthcare provider that summarizes a patient's hospitalization, including diagnosis, treatment provided, medications, and follow-up care instructions upon discharge from a hospital or medical facility
The discharge summary included the patient's diagnosis of pneumonia and prescribed antibiotics for home treatment.
O resumo de alta hospitalar incluía o diagnóstico de pneumonia do paciente e os antibióticos prescritos para tratamento em casa.
2. A clinical record that documents the reason for admission, hospital course, findings, procedures performed, and recommendations for ongoing care
The physician completed the discharge summary before the patient left the hospital.
O médico completou o resumo de alta antes do paciente sair do hospital.
In both Brazil and the USA, the discharge summary is a critical legal and medical document that serves as the official record of a patient's hospital stay. In Brazilian healthcare (both public SUS and private systems), it is essential for continuity of care with outpatient physicians and specialists. In the USA, it is required for insurance billing and quality assurance purposes. The document is typically provided to the patient and sent to their primary care physician.
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