Discharge summary: Difference between revisions
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− | ''' |
+ | # '''Date of Admission''' |
+ | # '''Date of Discharge''' |
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− | ''' |
+ | # '''Copies to all relevant Health Care Professional, Institutions''': includes GPs and MDs who have consulted and will follow up |
+ | # '''Most Responsible Diagnosis for Admission''' |
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+ | # '''Pre-Admit Comorbidities''' |
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− | *GP's |
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+ | # '''Post-Admit Comorbidities''' |
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− | *MD's who have consulted and will follow up |
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+ | # '''Secondary Diagnoses''' |
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+ | # '''Course In Hospital,''' or Principle Procedure, when applicable |
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− | '''3. Admission Diagnosis''' |
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+ | # '''Procedures and Treatments''', if applicable |
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− | ''' |
+ | # '''Discharge Medications''', including doses |
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− | '''5. Relevant Past Medial History & Past Surgical History''' |
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− | '''7. Course in Hospital''' |
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− | *History (clearly state reason for admission |
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− | *Investigations / Procedures |
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− | *Treatment / Surgery |
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− | *Consultants |
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− | *Areas of care (e.g. ICU, CCU) |
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− | '''8. Relevant Investigation / Procedures''' |
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− | *Echocardiogram |
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− | *Angiogram |
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− | *Pulmonary Function Tests |
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− | *Imaging |
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− | *Relevant Blood Tests (e.g. HbA1c if Diabetes) |
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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