Discharge Summary Note

ADMISSION/DISCHARGE DATES:

ADMISSION/DISCHARGE DIAGNOSES:

SERVICE: service name, attending, residents.

REFERRING PHYSICIAN:

CONSULTS: physicians, services, dates.

PROCEDURES: dates of surgery, lumbar punctures, angiograms, etc.

HISTORY, PHYSICAL EXAM: pertinent admission H&P and lab tests.

HOSPITAL COURSE: summary of the treatment and progress during hospital stay.

DISCHARGE CONDITION: good, stable, fair, guarded, critical, etc.

DISPOSITION: discharged to home, specific nursing home, etc.

MEDICATIONS: discharge meds with dosage, administration, refills, and or "Please see medication reconciliation sheet".

INSTRUCTIONS: activity restrictions, diet, dressing and/or cast care, symptoms to warrant further treatment, etc.

FOLLOW-UP: follow-up appointment, emergency phone number, etc.