Discharge Summaries

The true art of a discharge (d/c) summary is to be clear, concise, give only pertinent information, and describe what follow-up is essential. The goal should be to describe the reason for hospitalization, briefly summarize the hospital course, and to permit the primary MD to assume care of the patient after discharge.  NOTE: Each hospital has specific requirements regarding format, e.g. Letter vs. Basic format.

IDENTIFICATION:

1. Identify self, Attending MD on service at D/C, Service
2. List what the dictation is, e.g. D/C Summary, Clinic Visit
3. Identify the patient and spell full name
4. List the Pt's MR Number
5. List dates of admission and D/C

WHO'S IT GOING TO:

1. List name and address of Primary MD
2. List all carbon copies with addresses, e.g. consultants, social work, home health care agency, etc.

HISTORY of PRESENT ILLNESS (HPI):

This should be a concise and pertinent summary of the HPI and criteria for admission. Do not repeat the entire H&P.

PHYSICAL EXAM (PE) on ADMISSION:

Include vitals, wt, and all pertinent positives and negatives. Do not repeat your full PE from the chart.

ADMITTING LABS:

List significant labs, normals and abnormal values if pertinent. Do not list all labs obtained.

HOSPITAL COURSE:

You may dictate this section by problem list or by systems, e.g. fluids/electrolytes/nutrition (FEN), infectious disease (ID), hematologic (HEME), pulmonary (PULM), cardiovascular (CVS), gastrointestinal (GI), genitourinary (GU), neurological (NEURO), endocrine (ENDO), etc. However, brevity is the key, e.g. The pt was rehydrated with IVF's, not: the pt received D5W1/2NS + 20 KCL @ 50cc/hr.

D/C INFO:

1. D/C date
2. D/C diagnoses
3. D/C meds
4. F/U
5. Restrictions/Diet/Special Instructions etc.

CLOSING:

" It was a pleasure to be involved in ____'s medical care. Please do not hesitate to contact me if you have any questions or concerns."