Admissions Date:
Discharge Date:
Service: __________ ; Attending Physician: Dr. ________; Resident: Dr. _______
PCP / Referring Physician:
Discharge Diagnosis:
(Copy and paste problem list from last Progress Note)
Consultants:
- Name, MD/DO, Date
- Name, MD/DO, Date
- List all of them.
Procedures Performed:
- Name of the procedure, Date
- Name of the procedure, Date
- List all of them.
Hospital course:
– HPI on admission day (read/copy from what admission H&P says). Introduce the HPI with a Problem Presentation (Copy from last Progress Note)
– IN THE EMERGENCY ROOM: (name all the radiology tests that were done and what they showed)
– Dr._____(admitting physician) EVALUATED THE PATIENT IN THE EMERGENCY ROOM AND ADMITTED THE PATIENT FOR:
List admitting diagnoses i.e. assessment or problem list at admission (copy & paste from admission H& P)
Then explain what treatments were given for each admitting diagnosis. E.g. patient was started on Levaquin and Flagyl IV antibiotics. (Also see this in admission H&P). Here, include, “Please see admission H&P for details”
– Then continue to discuss what happened during the rest of the hospitalization including specialists you consulted and what each one did. Describing the hospital course on a problem-based fashion assists the receiving healthcare providers to quickly finding issues on specific problems. It also helps you organize the information and document it efficiently. For example:
#1. Heart failure (describing evaluation and treatment)
#2. Falls (list the contributing factors, evaluation, and treatment)
– I saw and evaluated the patient on the date of discharge. At this time (write your latest overnight subjective note)
Physical Exam at the Time of Discharge
Vitals:
[Insert vitals]
Physical Exam:
GENERAL: NAD, AOX3
HEENT: NC/AT, PERRLA. Conjunctivae, pink. Sclerae, anicteric, external ears are normal.
NECK: Supple, No lymphadenopathy or masses.
LUNGS: CTAB, No W/R/R, no use of accessory muscles of respiration.
HEART: RRR, no M/R/G, no heaves or thrills.
ABDOMEN: Normal BS, soft, NT/ND, No HSMG, not hyperresonant., no guarding or rebound tenderness
EXTREMITIES: No cyanosis, clubbing, or edema. 2+ peripheral pulses.
DERMATOLOGIC: No rashes
Labs:
[Insert labs]
Pending Studies:
None
Discharge Medications:
[Copy and paste from the “IP Patient Depart Summary” document generated by nurse]
Discharge Condition:
This patient is being discharged in a stable condition and expresses an understanding of this.
Disposition:
The patient is being discharged to home.
Discharge Instructions:
Resume home activities and a cardiac diet. Take all medications as instructed.
Follow up:
Call to set up follow up appointment with PCP, Dr. _____, in 5-7 days. Patient understands the importance of following up with a primary care physician.
Patient understands that if symptoms recur or if the patient has any symptoms similar to those that were present at this admission, the patient needs to consult the emergency department for further evaluation and treatment as well as call the PCP.
This discharge summary is made by Dr. _____ under the supervision of attending physician, Dr. ________, who saw and evaluated the patient with me.
———END of D/C Summary————–
Explanations of Items on the D/C Template Above.
Discharge Medications: List all medications the patient needs to take at home including doses, route, frequency, and date of the last dose when applicable. Do not list all the PRN medications you wrote for them at the hospital unless there is something they really need. If you have changed any of the patient’s admission medications this should be noted along with the rationale. (The rationale may already have been stated in the hospital course, which is fine.)
What is recommended is to list the medication list in its entirety, then list what medications were started during hospitalization, what was stopped and why, and any tapering schedules. If the patient is going to a nursing home it is recommended to include indications for each drug.
Discharge Condition: Good, stable, fair, guarded, critical, etc. Try to provide a brief functional and cognitive assessment e.g. “walking w/ walker”; “stable but confused and requires assistance w/ ADLs”.
Disposition: This is where the patient is going. Discharged to home; home with home health; discharged to daughter’s house; Skilled Nursing Facility; Psychiatry service
Discharge Instructions*: Be specific about activity level, diet, wound care, or other issues the patient’s doctor needs to know. This is different from the discharge instructions you give to patients which includes symptoms and signs to report or seek care for (e.g. “call Dr. ___ if temperature greater than 100” or “go to ER if chest pain returns”) and must be in a language they understand. Include a 24/7 call-back number.
Pending Studies: List all studies that are outstanding and to whom the results will be sent in the case of discharges.
Recommendations: Include any consults or studies
Follow-up*: Name of the doctor, specialty, and appointment location and time. If the patient is to schedule the appointment, then make sure you include the timeframe by which the patient should schedule the appointment. (e.g. “Patient to arrange an appointment time to be seen within two weeks.”)