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
