Discharge summary
From IDWiki
- Date of Admission
- Date of Discharge
- Copies to all relevant Health Care Professional, Institutions: includes GPs and MDs who have consulted and will follow up
- Most Responsible Diagnosis for Admission
- Pre-Admit Comorbidities
- Post-Admit Comorbidities
- Secondary Diagnoses
- Course In Hospital, or Principle Procedure, when applicable
- Procedures and Treatments, if applicable
- Discharge Medications, including doses
- Clearly state dose changes from admission meds and new meds
- Also include medications discontinued, with the reason to discontinuation
- Follow-up Plan
- Outline follow up plans clearly including all appointments, investigations arranged, and to be arranged and no-medical follow up (CCA, physiotherapy, social work, etc.)
- Clear instruction on things to follow up after discharge and by who
- Clear plan for the family physician on all active issues