12 Discharge Summary
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Discharge Summary
Patient's Name and Medical Record Number:
Date of Admission:
Date of Discharge:
Admitting Diagnosis:
Discharge Diagnosis:
Attending or Ward Team Responsible for Patient:
Surgical Procedures, Diagnostic Tests, Invasive Procedures:
Brief History, Pertinent Physical Examination, and Laboratory Data:
Describe the course of the patient's disease up until the time that the patient
came to the hospital, including physical exam and laboratory data.
Hospital Course: Describe the course of the patient's illness while in the
hospital, including evaluation, treatment, medications, and outcome of
treatment.
Discharged Condition: Describe improvement or deterioration in the patient's
condition, and describe present status of the patient.
Disposition: Describe the situation to which the patient will be discharged
(home, nursing home), and indicate who will take care of patient.
Discharged Medications: List medications and instructions for patient on taking
the medications.
Discharged Instructions and Follow-up Care: Date of return for follow-up care
at clinic; diet, exercise.
Problem List: List all active and past problems.
Copies: Send copies to attending, clinic, consultants.
Prescription Writing
· Patient's name:
· Date:
· Drug name and preparation (eg, tablets size): Lasix 40 mg
· Quantity to dispense: #40
· Frequency of administration: Sig: 1 po qAM
· Refills: None
· Signature
