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