Discharge notes structure

[Bright381]

Hi,

The discharge notes bring lots of useful details about a patient stay and I was interested in using the "physical exam" part to try and establish an "initial" clinical status.

I'm working with patients going through the ED (i.e that have a row in the table edstays) and I'm wondering if the physical exam section correspond to the examination at the arrival in the ED or at the arrival at the first (or later?) care unit / service following the ED, when such a section exists in the discharge note.

Thank you.

[alistairewj]

The discharge summary is written by the attending doctor at the end of the hospital stay (usually a bit after). Sometimes they will copy paste the physical exam section from an admission note, but they do have the ability to update the text of this section. My guess would be physical exam isn't updated that frequently so you're probably safe to use it.