DISCHARGE SUMMARY DICTATION TEMPLATE

DATE OF ADMISSION:

DATE OF DISCHARGE:

ADMISSION DIAGNOSIS (ES):

• Start from most pressing/important problem first
• Make sure to state other diagnoses that the patient has a history of (if it pertains to the admission and you are addressing it)

DISCHARGE DIAGNOSIS (ES):

• If the same as admission diagnosis, state whether resolved, improved, stable, etc.

DISCHARGE CONDITION:

• typically use words like “stable”

CONSULTATIONS:

• list all consults obtained during the hospital stay and the consultants’ names

PROCEDURES:

• list all procedures done during the hospital stay and include dates
• i.e., imaging studies, LPs, I&D’s, surgeries, etc.

BRIEF HPI:

• this should be no more than a paragraph. Try to include a brief 1-2 sentence summary of the ER course

HOSPITAL COURSE (by systems):

• should be brief, but MUST include pertinent labs, why procedures were done, etc.
• FEN/GI, CV, RESP, HEME, ID, NEURO, SOCIAL (Others may include RENAL/URO, RHEUM, etc)

DISCHARGE PHYSICAL EXAMINATION:

• MUST include admission and discharge weight!
• Include vitals upon discharge
• Complete physical exam

ACTIVITY:

DIET:

• When pertinent, please be specific (i.e., FTT patients, preemies, GERD patients, Chronic pts, etc)

MEDS:

• List all medications you are sending the patient home on, including dosages, quantities, and any specific instructions
• Please include scheduled appt time with PMD, any consultants and their phone numbers
• State that you have spoken to the PMD

DISCHARGE INSTRUCTIONS:

• “...Return to ER if…”, signs and symptoms to look out for, and that you educated the parents on their diagnosis (es) and their medications

Cc:

• PMD and address and/or fax number
• Any consultants and address, phone number and/or fax number