Discharge summary: Difference between revisions

Latest revision as of 16:17, 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
1. Clearly state dose changes from admission meds and new meds
2. Also include medications discontinued, with the reason to discontinuation
Follow-up Plan
1. Outline follow up plans clearly including all appointments, investigations arranged, and to be arranged and no-medical follow up (CCA, physiotherapy, social work, etc.)
2. Clear instruction on things to follow up after discharge and by who
3. Clear plan for the family physician on all active issues

@@ Line 1: / Line 1: @@
-'''1. Date of Admission and Date of Discharge'''
+# '''Date of Admission'''
+# '''Date of Discharge'''
-'''2. Copies to all relevant Health Care Professional, Institutions'''
+# '''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
-'''4. Discharge Diagnosis'''
+# '''Discharge Medications''', including doses
+## Clearly state dose changes from admission meds and new meds
+## Also include medications discontinued, with the reason to discontinuation
-'''5. Relevant Past Medial History & Past Surgical History'''
+# '''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.)
-'''6. Discharge Meds & Doses (clearly state dose changes from admission meds and new meds)'''
+## Clear instruction on things to follow up after discharge and by who
+## Clear plan for the family physician on all active issues
-* Also include medications discontinued, with the reason
-'''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'''
-* 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