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- COURSE: Patient remained stable and at discharge is tolerating oral intake at their baseline and is not deemed to have a fall risk. No significant issues raised by nursing remained unresolved.  Based on an appropriate medical screening exam there is currently no evidence of an emergency medical condition, but return precautions were given in case things change.  The patient and/or family were updated and are comfortable with the plan of care. 

- COUNSELING: The patient and/or family was counseled on the diagnosis, treatment and side effects (especially for any sedating medications), restrictions, need for follow-up and reasons to return here.  They were also told to call their PCP or referral doctor as soon as possible for more advice and/or to arrange a follow-up appointment and to have them obtain formal radiology reports and pending lab test results including cultures.  If blood pressure was elevated they were counseled on the importance of having this rechecked as an outpatient.

- TEST RESULTS: The patient and/or family was told that they needed to have any abnormal test results repeated with a follow-up doctor and that they need to have that doctor also obtain and discuss with them their final radiology reports and/or the final results of any cultures or other tests that were still pending at the time of discharge.  Copies of their preliminary lab and imaging reports were provided at discharge.

- RE-EXAM: Repeat exam at time of discharge shows:


from emresource.org

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