Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Admitting Physician:
Admitting Diagnosis:
Discharge Date:
Discharge Disposition (e.g., home, home with support services, transfer to another facility)
Reason for Admission
Briefly summarize the primary reason for the patient’s admission.
Summary of Hospital Course
Provide a concise overview of the patient’s clinical course during their stay.
Include key events, interventions, and responses to treatment.
Mention any significant investigations or procedures performed.
Discharge Diagnosis
List the definitive diagnosis or diagnoses established during the hospitalization.
Medications
List all medications the patient will be taking upon discharge, including:
Medication name
Dosage
Frequency
Route of administration (e.g., oral, intravenous)
Specific instructions (e.g., take with food, avoid alcohol)
Follow-up Instructions
Provide clear and specific instructions for the patient’s care after discharge.
Include details on:
Scheduled follow-up appointments with healthcare providers.
Wound care or medication administration instructions (if applicable).
Activity restrictions or rehabilitation recommendations.
Warning signs or symptoms to prompt the patient to seek medical attention.
Diet
Specify any dietary restrictions or recommendations for the patient to follow after discharge.
Social Support
Briefly address the patient’s social support system and any potential needs for assistance after discharge.
Education Provided
Briefly mention any patient education initiatives undertaken during the hospitalization (e.g., medication management, disease management strategies).
Prognosis
Provide a general outlook for the patient’s health after discharge, considering their condition and treatment plan.
Physician Notes
Include any additional comments or recommendations from the discharging physician.
Note: This is a general template, and additional sections may be necessary depending on the specific patient situation.
It’s crucial to tailor the discharge note to ensure clear communication and a smooth transition of care for the patient upon discharge.