What type of record contains a patient's diagnosis and the summary of care that has already been provided?

What type of record contains a patient's diagnosis and the summary of care that has already been provided?

• A. Discharge Summary
• B. Transfer Record
• C. Clinical Record
• D. Longitudinal Record

Answer: (B)

The type of record that contains a patient's diagnosis and the summary of care already provided is the discharge summary. A discharge summary is a critical component of a patient's medical record that serves to document the patient's condition at the time of discharge, it includes diagnoses, the course of treatment, and instructions for ongoing care post-discharge. It is specifically designed to provide a comprehensive overview of the care the patient received during their stay, making it essential for continuity of care, especially for follow-up services. This document is often used by healthcare providers who will be caring for the patient after discharge to understand the patient's treatment history, medication, and any outstanding health issues. While the clinical record details all clinical interactions over time, the transfer record is used during patient transitions between care settings or providers, and the longitudinal record provides a comprehensive view of a patient's health history over time but does not focus specifically on the summary of a single care episode as the discharge summary does.

The type of record that contains a patient's diagnosis and the summary of care already provided is the discharge summary. A discharge summary is a critical component of a patient's medical record that serves to document the patient's condition at the time of discharge, it includes diagnoses, the course of treatment, and instructions for ongoing care post-discharge.

It is specifically designed to provide a comprehensive overview of the care the patient received during their stay, making it essential for continuity of care, especially for follow-up services. This document is often used by healthcare providers who will be caring for the patient after discharge to understand the patient's treatment history, medication, and any outstanding health issues.

While the clinical record details all clinical interactions over time, the transfer record is used during patient transitions between care settings or providers, and the longitudinal record provides a comprehensive view of a patient's health history over time but does not focus specifically on the summary of a single care episode as the discharge summary does.