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    Sample Discharge Summary Template

    Uploaded by

    Bobby Reddy
    This document provides a template for a discharge summary that includes sections for demographic data, admission and discharge diagnoses, medical history, hospital course, discharge conditions and instructions, follow-up plans, and signatures. The template is intended to standardize documentation and includes fields for patient identifiers, reasons for admission, treatments during stay, comparison of conditions at admission and discharge, medication changes, and arrangements for ongoing care after discharge.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Sample Discharge Summary Template

    Uploaded by

    Bobby Reddy
    547 views3 pages
    This document provides a template for a discharge summary that includes sections for demographic data, admission and discharge diagnoses, medical history, hospital course, discharge conditions and instructions, follow-up plans, and signatures. The template is intended to standardize documentation and includes fields for patient identifiers, reasons for admission, treatments during stay, comparison of conditions at admission and discharge, medication changes, and arrangements for ongoing care after discharge.

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    This document provides a template for a discharge summary that includes sections for demographic data, admission and discharge diagnoses, medical history, hospital course, discharge conditions and instructions, follow-up plans, and signatures. The template is intended to standardize documentation and includes fields for patient identifiers, reasons for admission, treatments during stay, comparison of conditions at admission and discharge, medication changes, and arrangements for ongoing care after discharge.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    547 views3 pages

    Sample Discharge Summary Template

    Uploaded by

    Bobby Reddy
    This document provides a template for a discharge summary that includes sections for demographic data, admission and discharge diagnoses, medical history, hospital course, discharge conditions and instructions, follow-up plans, and signatures. The template is intended to standardize documentation and includes fields for patient identifiers, reasons for admission, treatments during stay, comparison of conditions at admission and discharge, medication changes, and arrangements for ongoing care after discharge.

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    DISCHARGE SUMMARY TEMPLATE

    Approved by the Provincial HIM Leadership Committee March 19, 2010

    DEMOGRAPHIC AND ADMINISTRATIVE DATA

    PATIENT NAME
    ADDRESS
    CHART NUMBER
    ACCOUNT NUMBER
    (Meditech Registration Account Number)
    HEALTH CARE NUMBER
    DOB
    GENDER
    ADMISSION DATE
    DISCHARGE DATE
    REFERRING PHYSICIAN
    MOST RESPONSIBLE PROVIDER (Attending physician)
    FAMILY PHYSICIAN
    ADMISSION DIAGNOSIS-
    Working diagnosis at time of admission ( Do not use abbreviations.)

    MOST RESPONSIBLE DIAGNOSIS (MRDx)


    The one diagnosis or condition that can be described as being most responsible for the
    patient’s stay in hospital (Do not use abbreviations.)

    PRE-ADMIT COMORBIDITY(IES)
    A condition(s) that coexists at the time of admission (Do not use abbreviations.)

    POST- ADMIT COMORBIDITY(IES)


    A condition(s) that arises post-admission (Do not use abbreviations. )

    SECONDARY DIAGNOSIS(ES)
    A secondary diagnosis(es) or condition(s) which may or may not have received treatment but does
    not impact on the patient’s LOS or treatment (Do not use abbreviations.)

    INTERVENTIONS
    Diagnostic and/or Therapeutic interventions performed during the current episode of care
    HISTORY OF PRESENT ILLNESS

    o Initial Presentation
    o Chief Complaint
    o Significant Findings
    o Relevant laboratory results
    o Allergies

    HOSPITAL COURSE
    Events occurring during the current episode of care, e.g. treatment given, response to
    treatment/interventions, abnormal or significant test results, results pending, description
    of complications, consults, etc.

    CONDITION AT DISCHARGE
    Provide comparison with condition at admission

    MEDICATIONS
    o Admission Medications
    o Changes made to regular medication regimen
    o Medications prescribed upon discharge
    o Drug Allergies
    o Adverse Drug Reactions encountered during the admission

    DISCHARGE INSTRUCTIONS

    o Diet
    o Activities
    o Medications
    o Therapy
    o Other instructions

    FOLLOW-UP
    Arrangements for ongoing care
    o Return appointments
    o Referral to other services
    o Discharge to (home, long term care, rehab, etc)

    SIGNATURE
    o Physicians Signature
    o Dictating Care Provider
    o Date/Time Dictated
    o Date/Time Transcribed
    o Recipients of copies of the Discharge Summary

    Discharge Summary Template 2


    2010-03-19
    References:
    Canadian Institute for Health Information. Canadian Coding Standards v2009 ICD-10-CA
    and CCI, Ottawa: Canadian Institute for Health Information, 2009

    LaTour, Kathleen and Eichenwald, S. Health Information Management: Concepts,


    Principles, and Practice. American Health Information Management Association,
    Chicago, 2002

    Physician Documentation Expert Panel. A Guide to Better Physician Documentation:


    What You Should Know About Physician Documentation. Toronto. November 2006

    eHealth Ontario, Ontario Discharge Summary Implementation Guide, V 1.3 (Final Draft).
    Toronto, September 30, 2009

    Canadian Health Information Management Association, Data for Electronic Patient


    Record Documentation, Professional Practice Brief – 0015.08. London, 2008

    Klaus, Anne and Lariviere, Sandra, Physician Discharge Documentation.


    William Osler Health Centre and the ON Ministry of Health and Long Term Care
    Presentation 2007 CHIMA Conference, Quebec City.

    Discharge Summary Template 3


    2010-03-19

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