Discharge summary: Difference between revisions

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# '''Post-Admit Comorbidities'''
 
# '''Post-Admit Comorbidities'''
 
# '''Secondary Diagnoses'''
 
# '''Secondary Diagnoses'''
  +
# '''Course In Hospital,''' or Principle Procedure, when applicable
# '''Principle Procedure''', when applicable, or course in hospital
 
# '''Other Procedures and Treatments'''
+
# '''Procedures and Treatments''', if applicable
 
# '''Discharge Medications''', including doses
 
# '''Discharge Medications''', including doses
 
## Clearly state dose changes from admission meds and new meds
 
## Clearly state dose changes from admission meds and new meds

Latest revision as of 12:17, 2 February 2022

  1. Date of Admission
  2. Date of Discharge
  3. Copies to all relevant Health Care Professional, Institutions: includes GPs and MDs who have consulted and will follow up
  4. Most Responsible Diagnosis for Admission
  5. Pre-Admit Comorbidities
  6. Post-Admit Comorbidities
  7. Secondary Diagnoses
  8. Course In Hospital, or Principle Procedure, when applicable
  9. Procedures and Treatments, if applicable
  10. 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
  11. 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