Discharge summary: Difference between revisions
From IDWiki
(Created page with "'''1. Date of Admission and Date of Discharge''' '''2. Copies to all relevant Health Care Professional, Institutions''' * GP's * MD's who have consulted and will follow up...") |
No edit summary |
||
| (2 intermediate revisions by the same user not shown) | |||
| Line 1: | Line 1: | ||
| − | ''' |
+ | # '''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''' |
||
| − | * GP's |
||
| + | # '''Post-Admit Comorbidities''' |
||
| − | * MD's who have consulted and will follow up |
||
| + | # '''Secondary Diagnoses''' |
||
| − | |||
| + | # '''Course In Hospital,''' or Principle Procedure, when applicable |
||
| − | '''3. Admission Diagnosis''' |
||
| + | # '''Procedures and Treatments''', if applicable |
||
| − | |||
| − | ''' |
+ | # '''Discharge Medications''', including doses |
| ⚫ | |||
| − | |||
| ⚫ | |||
| − | '''5. Relevant Past Medial History & Past Surgical History''' |
||
| + | # '''Follow-up Plan''' |
||
| − | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| − | |||
| ⚫ | |||
| ⚫ | |||
| − | |||
| − | '''7. Course in Hospital''' |
||
| − | |||
| − | * History (clearly state reason for admission |
||
| − | * Investigations / Procedures |
||
| − | * Treatment / Surgery |
||
| − | * Consultants |
||
| − | * Areas of care (e.g. ICU, CCU) |
||
| − | |||
| − | '''8. Relevant Investigation / Procedures''' |
||
| − | |||
| − | * Echocardiogram |
||
| − | * Angiogram |
||
| − | * Pulmonary Function Tests |
||
| − | * Imaging |
||
| − | * Relevant Blood Tests (e.g. HbA1c if Diabetes) |
||
| − | |||
| − | '''9. Issues & Follow-up Instructions''' |
||
| − | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
Latest revision as of 12:17, 2 February 2022
- 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
