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
Principle Procedure, when applicable, or course in hospital
Other Procedures and Treatments
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