454 lines
12 KiB
Markdown
454 lines
12 KiB
Markdown
# Discharge Summary Template
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## Patient Information
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**Patient Name:** [Last, First]
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**Medical Record Number:** [MRN]
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**Date of Birth:** [MM/DD/YYYY]
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**Age:** [years]
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**Sex:** [M/F]
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**Admission Date:** [MM/DD/YYYY]
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**Discharge Date:** [MM/DD/YYYY]
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**Length of Stay:** [X days]
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**Admitting Service:** [Medicine/Surgery/Cardiology/etc.]
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**Attending Physician:** [Name]
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**Primary Care Physician:** [Name and contact]
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**Consulting Services:** [List specialties that saw patient]
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---
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## Admission Diagnosis
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[Primary reason for hospitalization]
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Example: "Acute decompensated heart failure"
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---
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## Discharge Diagnoses
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[Numbered list, prioritized by clinical significance]
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**Primary Diagnosis:**
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1. [Primary diagnosis with ICD-10 code]
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**Secondary Diagnoses:**
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2. [Secondary diagnosis with ICD-10 code]
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3. [Additional diagnosis with ICD-10 code]
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4. [Comorbidity with ICD-10 code]
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Example:
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```
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1. Acute decompensated heart failure (I50.23)
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2. Acute kidney injury on chronic kidney disease stage 3 (N17.9, N18.3)
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3. Hypokalemia (E87.6)
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4. Type 2 diabetes mellitus (E11.9)
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5. Coronary artery disease (I25.10)
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```
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---
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## Hospital Course
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[Comprehensive yet concise narrative of hospital stay - can be organized chronologically or by problem]
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### Chronological Format:
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**[Date Range or Hospital Day 1-X]:**
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[Patient Name] was admitted to the [service] service with [chief complaint/presenting problem]. On presentation, patient was [clinical status]. Initial workup revealed [key findings].
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[Description of key events, interventions, and response to treatment organized by day or by problem]
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**Hospital Day 1:** [Events and interventions]
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**Hospital Day 2-3:** [Progression, response to treatment]
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**Hospital Day 4-7:** [Continued treatment, consultations, procedures]
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**Final Hospital Days:** [Stabilization, preparation for discharge]
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### Problem-Based Format (Alternative):
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**1. [Primary Problem]**
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- Presentation and initial management
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- Diagnostic workup
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- Treatment course
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- Response and outcome
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- Status at discharge
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**2. [Secondary Problem]**
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- [Similar structure]
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**3. [Additional Problems]**
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### Key Events and Interventions
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**Consultations Obtained:**
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- [Specialty] consulted on [date] for [reason]: [Recommendations]
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**Procedures Performed:**
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- [Procedure name] on [date]: [Indication, findings, complications if any]
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**Significant Diagnostic Studies:**
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- [Test/imaging] on [date]: [Key findings relevant to discharge care]
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**Complications:**
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- [Any complications that occurred]: [How managed]
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---
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## Procedures Performed During Hospitalization
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1. [Procedure name] ([Date])
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- Indication: [Why performed]
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- Findings: [Key findings]
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- Complications: [None / specific complications]
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2. [Additional procedures]
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---
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## Hospital Course Summary (Brief Version)
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[One paragraph summary suitable for quick reference]
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Example:
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```
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Mr. [Name] was admitted with acute decompensated heart failure in the setting of
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medication non-adherence. He was diuresed with IV furosemide with net negative
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5 liters over 3 days, with significant improvement in dyspnea and resolution of
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lower extremity edema. Echocardiogram showed EF 30%, similar to prior. Kidney
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function improved to baseline with diuresis. He was transitioned to oral diuretics
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on hospital day 3 and remained stable. Patient was ambulating without dyspnea on
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room air by discharge. Comprehensive heart failure education was provided.
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```
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---
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## Discharge Physical Examination
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**Vital Signs:**
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- Temperature: \_\_\_\_\_ °F
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- Blood Pressure: \_\_\_\_\_/\_\_\_\_\_ mmHg
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- Heart Rate: \_\_\_\_\_ bpm
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- Respiratory Rate: \_\_\_\_\_ breaths/min
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- Oxygen Saturation: \_\_\_\_\_% on [room air / O2]
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- Weight: \_\_\_\_\_ kg (Admission weight: \_\_\_\_\_ kg)
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**General:** [Appearance, distress level]
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**Cardiovascular:** [Heart sounds, edema]
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**Pulmonary:** [Breath sounds, work of breathing]
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**Abdomen:** [Tenderness, bowel sounds, distention]
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**Extremities:** [Edema, pulses]
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**Neurological:** [Mental status, focal deficits]
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**Wounds/Incisions (if applicable):** [Healing status]
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---
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## Pertinent Laboratory and Imaging Results
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### Discharge Labs ([Date])
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| Test | Result | Reference Range |
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|------|--------|----------------|
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| WBC | [Value] | [Range] |
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| Hemoglobin | [Value] | [Range] |
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| Platelets | [Value] | [Range] |
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| Sodium | [Value] | [Range] |
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| Potassium | [Value] | [Range] |
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| Creatinine | [Value] | [Range] |
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| [Other relevant labs] | [Value] | [Range] |
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### Imaging/Diagnostic Studies
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**[Study name] ([Date]):** [Key findings relevant to outpatient management]
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---
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## Discharge Medications
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[Complete list with clear indication of changes from admission]
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### New Medications (Started During Hospitalization)
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1. **[Medication name]** [dose] [route] [frequency]
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- Indication: [Why prescribed]
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- Duration: [If limited duration]
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- Special instructions: [With food, time of day, etc.]
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### Changed Medications (Dose or Frequency Modified)
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2. **[Medication name]** [NEW dose] [route] [frequency]
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- **CHANGED FROM:** [Previous dose and frequency]
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- Reason for change: [Why modified]
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### Continued Medications (No change from home medications)
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3. **[Medication name]** [dose] [route] [frequency]
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- **CONTINUED** from home regimen
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### Discontinued Medications (Stopped During Hospitalization)
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4. **[Medication name]** - **DISCONTINUED**
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- Reason: [Why stopped]
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### Complete Medication List for Patient
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[Consolidated list in simple format for patient]
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```
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1. Furosemide 40 mg by mouth once daily [NEW - for fluid management]
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2. Carvedilol 12.5 mg by mouth twice daily [CONTINUED]
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3. Lisinopril 20 mg by mouth once daily [CONTINUED]
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4. Metformin 1000 mg by mouth twice daily [CONTINUED]
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5. Aspirin 81 mg by mouth once daily [CONTINUED]
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```
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---
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## Discharge Condition
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**Overall Status:** [Stable / Improved / Baseline / Requires continued care]
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**Specific Assessments:**
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- Hemodynamic status: [Stable]
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- Respiratory status: [Room air / Oxygen requirement]
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- Mental status: [Alert and oriented x3 / Other]
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- Functional status: [Ambulatory / Requires assistance / Bedbound]
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- Pain control: [Adequate / Inadequate]
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- Wound healing (if applicable): [Appropriate / Delayed]
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Example:
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```
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Patient is hemodynamically stable, ambulatory without assistance, no supplemental
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oxygen requirement, euvolemic on physical exam, pain well-controlled, and has
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returned to baseline functional status.
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```
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---
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## Discharge Disposition
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[Where patient is going after hospital discharge]
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Options:
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- Home with self-care
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- Home with home health services
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- Skilled nursing facility
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- Acute rehabilitation facility
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- Long-term acute care hospital
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- Hospice (home or facility)
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- Left against medical advice (AMA)
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- Transferred to another acute care facility
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**Discharge Disposition:** [Selection from above]
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**Services Arranged:**
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- [ ] Home health nursing
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- [ ] Physical therapy
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- [ ] Occupational therapy
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- [ ] Durable medical equipment: [List items]
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- [ ] Home oxygen: [Flow rate and delivery method]
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- [ ] Other: [Specify]
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---
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## Follow-Up Appointments
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1. **[Specialty/PCP]** with Dr. [Name]
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- Date/Time: [Scheduled date and time] OR [Within X days/weeks]
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- Location: [Clinic name and address]
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- Phone: [Contact number]
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- Purpose: [What needs to be addressed]
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2. **[Additional appointments]**
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### Pending Studies/Labs at Discharge
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- [Test name]: [When due, where to go, reason]
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- Results will be sent to: [Provider name]
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### Referrals Placed
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- [Specialty]: [Reason for referral, contact information]
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---
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## Patient Instructions
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### Activity
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- [Specific activity restrictions or recommendations]
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- Example: "Resume normal activities as tolerated. Avoid heavy lifting >10 lbs for 2 weeks."
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### Diet
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- [Dietary restrictions or recommendations]
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- Example: "Low sodium diet (less than 2 grams per day). Fluid restriction to 2 liters per day."
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### Wound Care (if applicable)
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- [Incision care instructions]
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- [Dressing change frequency]
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- [When stitches/staples should be removed]
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### Self-Monitoring
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- [What patient should monitor at home]
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- Example: "Weigh yourself every morning. Call doctor if weight gain >2 lbs in 1 day or >5 lbs in 1 week."
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### Equipment/Supplies
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- [Equipment provided or prescribed]
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- [How to use]
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### Medications
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- [General medication instructions]
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- [Importance of compliance]
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- [What to do if dose missed]
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---
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## Return Precautions / Warning Signs
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**Call your doctor or return to emergency department if you experience:**
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- [Specific warning signs relevant to condition]
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- [When to seek immediate care vs. call doctor]
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Example for heart failure:
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```
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- Worsening shortness of breath or difficulty breathing
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- Chest pain or pressure
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- Severe swelling in legs or abdomen
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- Weight gain more than 2 lbs in one day or 5 lbs in one week
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- Dizziness, lightheadedness, or fainting
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- Fever >101°F
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- Any other concerning symptoms
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```
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**Emergency Contact Numbers:**
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- Primary care physician: [Phone]
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- Specialty clinic: [Phone]
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- After-hours nurse line: [Phone]
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- 911 for emergencies
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---
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## Patient Education Provided
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Topics discussed with patient and/or family:
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- [ ] Disease process and prognosis
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- [ ] Medication purpose, dosing, and side effects
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- [ ] Warning signs and when to seek care
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- [ ] Activity and dietary restrictions
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- [ ] Follow-up appointments
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- [ ] Use of medical equipment
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- [ ] [Other specific topics]
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**Patient/Family Understanding:**
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[Patient and family verbalize understanding of discharge instructions / Teach-back method used and patient able to repeat key points / Interpreter used]
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**Written Materials Provided:**
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- [ ] Discharge instructions
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- [ ] Medication list
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- [ ] Disease-specific education materials
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- [ ] Emergency contact information
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- [ ] Appointment information
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---
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## Code Status at Discharge
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**Code Status:** [Full code / DNR / DNI / Other limitations]
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[If changed during hospitalization, note when and why]
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---
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## Additional Information
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### Advance Directives
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- [ ] Advance directive on file
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- [ ] Healthcare proxy designated: [Name and contact]
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- [ ] Living will present
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### Social Situation
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[Relevant social factors affecting discharge plan]
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- Living situation: [Lives alone / with family / assisted living]
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- Caregiver support: [Available / Limited / None]
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- Transportation: [Adequate / Needs assistance]
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- Barriers to compliance: [Financial / Cognitive / Language / Other]
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### Pending Issues at Discharge
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[Tests or consultations still pending that require outpatient follow-up]
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---
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## Signature
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**Prepared by:**
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[Physician name, credentials]
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[Pager/Contact number]
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**Cosigned by (if resident/fellow):**
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[Attending physician name]
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**Date and Time:** [MM/DD/YYYY at HH:MM]
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**Electronically signed:** [Yes/No]
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---
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## Template Completion Checklist
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- [ ] All discharge diagnoses listed with ICD-10 codes
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- [ ] Hospital course summarized clearly
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- [ ] All procedures documented
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- [ ] Discharge medications reconciled and clearly marked (new/changed/continued/stopped)
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- [ ] Follow-up appointments scheduled or timeframe provided
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- [ ] Patient education documented
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- [ ] Return precautions specific to patient's conditions
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- [ ] Pending tests/results documented with follow-up plan
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- [ ] Code status documented
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- [ ] Completed within 24-48 hours of discharge (institutional requirement)
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- [ ] Sent to primary care physician and relevant specialists
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- [ ] Copy provided to patient
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---
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## Notes
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**Timing Requirements:**
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- CMS requires completion within 30 days
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- Many hospitals require 24-48 hours
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- Should be available for follow-up appointments
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**Distribution:**
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- Send to primary care physician
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- Send to referring physician
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- Send to consulting specialists involved in care
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- Provide copy to patient
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- Upload to shared HIE (Health Information Exchange)
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**Quality Measures:**
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- Medication reconciliation required
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- Clear communication of changes
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- Specific follow-up plans
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- Patient education documented
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