Rehabilitation Discharge Summary Medical Transcription Sample For Medical Transcriptionists


Medical Transcription Rehab Discharge Summary Sample Report:
 
ADMISSION DIAGNOSES:
1.  Osteoarthritis, status post right total knee arthroplasty.
2.  Impaired mobility and self-care activities.
3.  Postoperative anemia.
4.  Hypothyroidism.
5.  Diverticulitis.
6.  Obesity.
7.  Constipation.

DISCHARGE DIAGNOSES:
1.  Osteoarthritis, status post right total knee arthroplasty.
2.  Impaired mobility and self-care activities.
3.  Postoperative anemia.
4.  Hypothyroidism.
5.  Diverticulitis.
6.  Obesity.
7.  Constipation.
8.  Dyspepsia with nausea.
9.  Moderate swelling of the right knee with peripheral edema.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old white female with progressive and severe pain at the right knee due to osteoarthritis.  The patient also developed flexion contracture of the right knee.  The patient failed conservative treatment and was in need of surgical intervention.  Therefore, the patient was admitted to the acute hospital and underwent right total knee arthroplasty with release of contractures by Dr. Doe.  The patient had postoperative anemia and severe difficulty with mobility due to pain and weakness of the right lower extremity.  The patient was in need of acute and comprehensive rehabilitation and was admitted to the rehabilitation hospital.

HOSPITAL COURSE:  At the time of admission, the patient had moderate anemia with hemoglobin of 10 and hematocrit of 29.5.  The patient complained of some discomfort on the skin of the back due to history of shingles.  No acute intervention was necessary.  Diverticulitis and constipation were stable.  The patient developed some nausea and dyspepsia, which were resolved with medication intervention.  Anemia was stable with the latest hemoglobin of 10.1 and hematocrit of 37.1.  The patient had moderate swelling around the knee, which was treated with ice packs.  There was evidence of peripheral edema of the lower extremities.  The patient’s incision was well healed and remained clean and dry.  There is no calf tenderness or evidence of DVT.  The patient was maintained on Arixtra during the hospitalization, and this was discontinued just prior to discharge.  Overall, the patient made good improvement.

Functionally, the patient is at supervised level for bed mobility and also supervised to modified independent level for functional transfers.  The patient is able to ambulate up to 150 feet with a front-wheel walker.  Range of motion of the knee is actively 4 to 84 degrees and passively 0 to 94 degrees.  The patient is at supervised level for eating, grooming, bathing and minimal assistance level for lower body dressing.  The patient requires supervision for bathroom transfers.  The patient was continent of bowel and bladder.  Discharge planning was done.  The patient was eager to go home and was discharged to home.

CONDITION AT DISCHARGE:  Medically stable.

FUNCTIONAL STATUS:  See above for functional status.

DISPOSITION:  The patient is being discharged to home with family assistance.

DISCHARGE MEDICATIONS:  Prescription was written for Darvocet-N 100 one p.o. t.i.d. p.r.n., #30.  The patient will resume home medications including thyroid 60 mg p.o. daily and multiple supplements.

FOLLOWUP:  The patient will be followed by Dr. Doe.  The patient will have outpatient physical therapy three times a week for three weeks.  The patient will be followed by Dr. Smith, primary MD, as needed in the future.

DISCHARGE DIET:  Regular as tolerated.

DISCHARGE EQUIPMENT:  The patient has a front-wheel walker.  Bedside commode was ordered.
 



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