Download Spinal Cord Injury

Spinal Cord Injury
Physician Discharge Summary
Date of Admission:
Date of Injury/Onset:
Date of Discharge:
Primary Rehab Diagnosis:
Etiologic Diagnosis:
Orthopedic Surgeon:
DISCHARGE DIAGNOSES:
PROCEDURES:
CONSULTING MDs:
HPI:
PAST MEDICAL HISTORY:
Negative
HOSPITAL COURSE BY PROBLEM:
1. Neurological:
2. Ortho:
3. Neurogenic Bladder:
3. Neurogenic Bowel:
4. DVT prophylaxis:
5. Skin:
6.
7. Pain:
8.
9. ID:
10. Psychiatric:
DISCHARGE PHYSICAL EXAM
GENERAL APPEARANCE:
HEENT:
LUNGS:
CARDIAC:
ABDOMEN:
EXTREMITIES: see ASIA exam sheet.
RANGE OF MOTION/CONTRACTURES:
SKIN:
VASCULAR:
Neurological Exam:
Cooperation with exam:
Orientation:
Recent and Remote Memory:
Attention Span and Concentration:
Communication (comprehension & expression):
Fund of Knowledge (e.g. awareness of current events):
Cranial Nerves:
ASIA (American Spinal Injury Association) exam:
Sensation:
Light Touch:
Pinprick:
Motor Strength:
Rectal:
Functional Status and Discharge FIM Scores:
Self Care
Eating: On admission, patient was
Grooming: On admission, patient was
Bathing: On admission, patient was
Dressing Upper: On admission, patient was
Dressing Lower: On admission, patient was
Toileting: On admission, patient was
Sphincter Control
Bladder Level of Assistance: On admission, patient was
Bladder Frequency of Accidents: On admission, patient was
Bowel Level of Assistance: On admission, patient was
Bowel Frequency of Accidents: On admission, patient was
Transfers
Bed, Chair, Wheelchair: On admission, patient was
Toilet: On admission, patient was
Tub/Shower: On admission, patient was
Locomotion
Walk: On admission, patient was
Wheelchair: On admission, patient was
Stair Climbing: On admission, patient was
Communication
Comprehension: On admission, patient was
Expression: On admission, patient was
Social
Social Interaction: On admission, patient was
Problem solving: On admission, patient was
Memory: On admission, patient was
ALLERGIES:
DISCHARGE PLAN:
DISCHARGE MEDICATIONS:
DISCHARGE EQUIPMENT:
DISCHARGE DIET:
DISCHARGE PHYSICAL ACTIVITY:
DISCHARGE PAIN MANAGEMENT PLAN:
DISCHARGE INSTRUCTIONS/FOLLOWUP: