Discharge summary template

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
  • Consultants
  • Procedures
  • Physical examination on discharge
  • Lab data
  • Disposition (transfer to)
  • Discharge medication
  • Discharge instructions

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