Discharge summary: Difference between revisions
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'''2. Copies to all relevant Health Care Professional, Institutions''' |
'''2. Copies to all relevant Health Care Professional, Institutions''' |
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| − | * |
+ | *GP's |
| − | * |
+ | *MD's who have consulted and will follow up |
'''3. Admission Diagnosis''' |
'''3. Admission Diagnosis''' |
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'''6. Discharge Meds & Doses (clearly state dose changes from admission meds and new meds)''' |
'''6. Discharge Meds & Doses (clearly state dose changes from admission meds and new meds)''' |
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| − | * |
+ | *Also include medications discontinued, with the reason |
'''7. Course in Hospital''' |
'''7. Course in Hospital''' |
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| − | * |
+ | *History (clearly state reason for admission |
| − | * |
+ | *Investigations / Procedures |
| − | * |
+ | *Treatment / Surgery |
| − | * |
+ | *Consultants |
| − | * |
+ | *Areas of care (e.g. ICU, CCU) |
'''8. Relevant Investigation / Procedures''' |
'''8. Relevant Investigation / Procedures''' |
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| − | * |
+ | *Echocardiogram |
| − | * |
+ | *Angiogram |
| − | * |
+ | *Pulmonary Function Tests |
| − | * |
+ | *Imaging |
| − | * |
+ | *Relevant Blood Tests (e.g. HbA1c if Diabetes) |
| − | '''9. |
+ | '''9. Discharge 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 |
Revision as of 16:58, 14 May 2021
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
3. Admission Diagnosis
4. Discharge Diagnosis
5. Relevant Past Medial History & Past Surgical History
6. Discharge Meds & Doses (clearly state dose changes from admission meds and new meds)
- 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. Discharge 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
