Rehab Discharge Summary Medical Transcription Sample
DISCHARGE DIAGNOSES:
1. Disability/mobility.
2. Disability of activities of daily living.
3. Spasticity.
4. Neurogenic bladder.
5. Contractures of upper extremities.
6. C5 ASIA C SCI.
7. Recurrent urinary tract infections.
8. Recurrent skin breakdowns.
9. Status post tracheostomy closure.
10. Recurrent pneumonia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who sustained a C5 spinal cord injury on MM/DD/YYYY with resulting quadriplegia. He was initially evaluated and treated at XYZ Hospital and was noted to have C1, C4, C5 and C6 fractures. He had a prolonged hospitalization requiring a tracheostomy tube, PEG tube, and ultimately recovered and was sent home. However, he has not had access to healthcare since that time, except for the routine visits to the emergency room. Recently, he did gain benefits through litigation and was admitted to neurological rehabilitation for further evaluation. Since his accident, he has had overflow incontinence and currently has a Foley catheter in place.
HOSPITAL COURSE: The patient was admitted to rehab on MM/DD/YYYY. The patient participated in inpatient acute rehabilitation program, which included interdisciplinary PT, OT, speech language pathology, rehab nursing, case management, therapeutic recreation, neuropsychiatry, and physiatry.
1. Disability/mobility: Upon admission, the patient was totally dependent for bed mobility, transfer mobility, and wheelchair mobility. The patient had been lying in a bed for well over a year without getting up out of the bed. The patient participated in interdisciplinary PT, OT, TR mobility programs and he progressed well. At discharge, the patient had improved to being able to drive a powered wheelchair with proportional head control. The patient was utilizing a switch with the right elbow and able to tilt to complete weight shifts. The patient was working on rolling to right and left with maximum assistance using leg straps, and the patient was transitioning from side-lying to sitting with maximum assistance of one. The patient was able to direct staff to help him complete 20-minute weight shift in the manual wheelchair.
2. Disability of ADLs: Upon admission, the patient was totally dependent for ADL care, bathing, grooming, and eating. The patient participated in interdisciplinary OT/rehab nursing ADL program and progressed well at discharge. The patient was able to wipe his face with his right hand with minimum to moderate assistance. The patient’s caregiver/family were receiving education on how to position the patient and transfer the patient at discharge.
3. Community reentry: Upon admission, the patient was completely bed bound and house bound. The patient participated in the OT/therapeutic recreation community reentry program, and he progressed well. At discharge, the patient was working on learning resources that were available to him and how to access them. The patient had been set up with a peer mentor that he could talk to, who was six years post injury.
DISCHARGE MEDICATIONS: The patient was discharged on Percocet 1-2 tablets q.6 h. p.r.n., Senokot two tablets b.i.d., baclofen 20 mg q.i.d., and Neurontin 600 mg t.i.d.
