Download Brochure - Society of Hospital Medicine

DISCHARGE SUMMARY
FORMAT
REMINDERS
DISCHARGE SUMMARY FORMAT
If the discharge summary is completed more
than 24 hours prior to discharge, an
addendum is required.
Admitting Diagnosis
Discharge summaries should be concise,
preferably no longer than two to three
pages.
Procedures
Do not use any dangerous abbreviations.
Common examples include:
Use “daily” instead of qd
Use “every other day” instead of qod
Use “units” instead of iu or u
Principal Discharge Diagnosis
Secondary Diagnoses
Attending MD and phone #
Primary Care MD
Consultations
Discharge Medications
Anticoagulation
Allergies/Adverse Drug Reactions
Do not forget to reconcile admission and
discharge medications.
Discharge Treatments
The principal discharge diagnosis is the
condition established after study to be
chiefly responsible for admission to the
hospital.
Follow-up & Outstanding Issues/Tests
Diet/Nutrition/Activity
Presentation on Admission
(including admission medication list)
Hospital Course
Code Status/Advanced Directives
Communication with PCP
Disposition
To Dictate:

Insert dictation system
instructions here.
I
DISCHARGE SUMMARY
Admitting Diagnosis
Principal Discharge Diagnosis
Secondary Diagnoses- Present on admission
Secondary Diagnoses- Acquired after
admission
II
Presentation on Admission (brief, focused,
pertinent):
Chief Complaint
History of present illness
PMH/PSH
Procedures Performed
Medication on Admission
Procedure, Date, Findings
Name, dose, route, frequency (obtain data from
medication reconciliation sheet)
Attending Physician/Contact MD at
Hospital
Name and phone number
Admission physical exam (brief, focused,
SPECIAL POPULATIONS
CHF Patients
Include: Discharge weight
Target weight and blood pressure
Most recent BUN, creatinine, Na, K, EF with
date
If not on beta blockers, why not?
If not on ACE-I or ARB, why not?
Document discharge instructions given
(activities, diet, meds, follow-up appointment,
daily weight and signs/symptoms of worsening
CHF)
pertinent)
Diabetes Patients – If not on ACE-I or
PCP
Pertinent Admission Labs and
Diagnostic Studies
ARB, explain why. Document Pneumovax and
influenza vaccine (October-March). Administer
if needed. Last known HgbA1C and date.
Consultations
Hospital Course by Problem or
Diagnosis Including:
Name and phone number if other than attending
Service, doctor’s name, phone number
Discharge Medications
Name, dose, route and frequency. Indicate
changes from admission meds
Anticoagulation
Agent(s) used, indication, target INR, anticipated
duration and follow up plan (responsible MD or
clinic and lab follow up). Last three INRs and
warfarin doses if warfarin is new drug or dose
changed
Allergies/Adverse Drug Reactions
Medication and type of reaction
Discharge Treatments
PT, OT, Nursing, Wound Care/Suture Removal
Diet/Nutrition/Activity
Consultations- service/names
Treatment rendered and response to treatment
Medication changes
Pertinent tests/labs with results
Procedure with results
Complications
Condition at Discharge
Follow-up including any problem that needs
close attention
MI Patients – If patient not on ASA, beta
blocker, statin or ACE-I/ARB at discharge
explain why
Orthopedic Patients
DVT Prevention, Wound Care, Activity
Patients > 65 - Document Pneumovax and
influenza vaccine (October-March). Administer
if needed
Pediatric Patients
Code Status/Advanced Directives
Hearing test, Hep B, car seat challenge, Synagis
given or indicated in winter, state screen, d/c
weight, length and head circumference
Communication with PCP
Surgical Patients
Document date and method of communication
of patient handoff with PCP
Disposition:
Home with VNA, rehab, SNF, hospital transfer
or expired
Wound care, Activity level,
Follow-up plans with Surgeon
Smokers
Document whether tobacco cessation
counseling was provided
Follow-up post discharge
MD follow-up (include date or approximate time
frame), pending test results and specific
problems that require further testing/monitoring
Created by: Adrienne Bennett, MD, PhD