C-ondition & C-ode status if known (If a DC summary will not accompany patient: list status at discharge of problems treated in hospital.)

 

Condition; describing the ADL status and status of their main medical problem will assist the receiving providers and institutions greatly.  It will give them the baseline and an idea of the necessary support systems for the patient.  ADLs can be remembered as the things we needed to be able to do to  go to kindergarten or through the mnemonic DEATH.  (D ress, E at-A mbulate-T oilet/Transfer- H ygiene).

Example: "heart failure status is stable and euvolemic and he is able to perform all ADLs except his bathing and needs standby assist to transfer."


Code status;
should not only include resuscitation, (e.g. DNR-DNI) but also any key discussions or information related to overall goals of care or the desirability of future use of hospital level technology.  For example; "the patient acquired a new terminal diagnoses and through counseling patient/family they may now decide to forgo further hospitalizations.  (DNH = Do Not Hospitalize)".