It is the single most important part of the medical record.
- Do document the short story of the patients illness through discharge and future planned care.
- Summary of all conditions, diseases, findings and treatments
- Convincing documentation of the maximum severity of illness of the admission
The following items should be on all discharge summaries
- Date of admission
- Date of discharge
- Date of birth
- Principle diagnosis
- Secondary diagnoses (list all)
- Hospital course
- Physical examination on discharge
- Lab data
- Disposition (transfer to)
- Discharge medication
- Discharge instructions