DA Form 3888-3. Medical Record - Nursing Discharge Summary
The DA Form 3888-3, known as the Medical Record - Nursing Discharge Summary, is used to document a summary of the nursing care provided to a patient upon their discharge from a healthcare facility. This form is typically utilized by nurses or other healthcare professionals involved in the patient's care and transition process.
The form consists of sections that capture important information related to the nursing care provided during the patient's stay. These sections include patient details, medical history, nursing diagnoses, interventions, outcomes, and discharge instructions. The form provides fields for recording the patient's name, age, gender, and other identifying information.
When filling out the DA Form 3888-3, it is crucial to provide an accurate and concise summary of the nursing care provided. Patient details, such as name and date of birth, should be recorded correctly to ensure proper and avoid any confusion.
The medical history section allows for documenting relevant past medical conditions, surgeries, allergies, and medications. The nursing diagnoses section provides space to summarize the nursing diagnoses identified during the patient's stay.
The interventions and outcomes sections outline the nursing actions taken and the resulting patient outcomes. This includes documenting the specific nursing interventions implemented to address the identified nursing diagnoses and evaluating the effectiveness of those interventions.
The discharge instructions section provides guidance and information for the patient and their caregivers regarding post-discharge care, medication instructions, follow-up appointments, and any necessary lifestyle modifications.
An example application of the DA Form 3888-3 would be in a hospital setting where nurses are responsible for documenting the nursing care provided to patients upon their discharge. By using this form, nurses can summarize the patient's nursing care journey, including diagnoses, interventions, and outcomes. The form serves as a tool for communication among healthcare providers, continuity of care, and providing essential information to the patient and their caregivers for a smooth transition from the healthcare facility to home or another care setting.