Discharge summary

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. 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