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When You Are Hospitalized, Take Notes

Whenever you are hospitalized for any reason, you or a family member, should write down all of the diagnoses made during the hospital stay. It is not uncommon for new diagnoses to come to light during a hospital stay for a completely unrelated reason, especially in those individuals who do not see a physician regularly.

These days, insurance companies mandate efficient, relevant hospital care. If a person is admitted for IV fluids due to dehydration, the insurance company is not going to be pleased if the doctor undertakes a big diagnostic work-up for minor conditions, such as mild anemia. Since in most instances, this type of work-up can be done safely in an outpatient setting, the insurance company may refuse to pay for any day in the hospital simply spent running tests. When the patient?s major illness improves, it is generally expected that he will be discharged home, and those issues that are not deemed critical will be addressed by his private physician in the outpatient setting.

If, by chance, your private physician is not the doctor who takes care of you in the hospital, there may be a significant lag before he receives a copy of the synopsis of events which occurred during your hospital stay. This typed synopsis, called the discharge summary, contains the highlights of the hospitalization, including which tests were done and their results, and each diagnosis and its treatment.

Unless you specifically request that your primary care doctor be sent a discharge summary, he may not automatically receive a copy, and he does not have the legal right to request it on your behalf. You must sign a ?release of records? form authorizing the hospital to mail or fax him this information if it was not requested while you were actually in the hospital. If your next appointment happens to be late in the afternoon, chances are the hospital?s medical records department will be closed, and your doctor will not have immediate access to this information. As a result, you may experience an avoidable delay in care and incur additional charges if there is a need for you to make another appointment once the discharge summary is received.

Upon discharge from the hospital, you will probably receive a general discharge instruction sheet, and you should add this to your medical journal. However, this sheet is often very basic, and does not contain a lot of detailed information, so it is wise to stop by the hospital?s medical records department on your way home to sign a release which would enable you to receive a copy of the discharge summary, once it is dictated and typed.


Be prepared for emergencies.

Keep a copy of vital health records in your purse at all times. Scan in EKGs, lab reports and other valuable information. Fill in charts allow you to keep track of medical problems, medications, allergies, appointments and MUCH MORE.

Go to Patient School


Go to Patient School


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Content copyright © 2013 by A. Maria Hester, M.D.. All rights reserved.
This content was written by A. Maria Hester, M.D.. If you wish to use this content in any manner, you need written permission. Contact Patricia Villani, MPA, PhD for details.

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