Discharge Summary Note
The longer version of the discharge summary, with the discharge condition, patient instructions and disposition spelled out.
It seems like no one really knows how to do these. They are usually dictated or typed into the medical record. The job is to let people know what happened during that hospitalization and how the patient was treated.
The date of admission.
A numbered list of all the acute diagnoses the patient had while hospitalized. This is not their past medical history. List them in order of importance and severity.
List all consultants and their field.
List all major procedures the patient had during the stay. You do not have to list minor things like a urinalysis. We are talking CT scans, stress tests, and the like.
Tells the story of the patient from admission until now: changes over time, lab studies, procedures, results, and what each consultant felt needed to be changed or adjusted.
Include the specifics and the changes each consultant made. Give cardiology their own paragraph, neurology their own paragraph, and so on for each service.
Their last set of vitals, with a date and time.
Good, stable, fair, guarded, critical.
Their final medication list and dosages. Do not simply write "see medication reconciliation sheet." If you want to refer to it, then also list here which medications were discontinued, which were added, and which dosages changed.
For example: "Please see the medication reconciliation list. Notable changes include his furosemide dose being changed to 40 mg twice daily and..."
What type of diet would you like them on? Low sodium? ADA 1200 calorie diet?
Can they resume full activity, or do you want them to avoid lifting heavy objects?
Daily weights, dressing or cast care, the symptoms that should prompt further treatment, and when to return to the hospital or call the doctor.
If you want a BMP in three days, give them the script and write it in here.
Follow up with the primary care physician in 1 week, cardiology in 2 weeks. List the names and phone numbers of the physicians you want them to see.
Home? Back to a skilled nursing facility? An assisted living center? Rehab? Be specific.
Remember that this is how the primary care physician who takes care of this patient finds out what you did to them while they were hospitalized, what they need to follow up on, and how their treatment and medications were changed.