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Objectives The fourth-year medical student will be able to write a complete discharge summary which will contain the necessary elements which contribute to a smooth care transition. Acknowledgments Society of Hospital Medicine: Adaptation of their discharge summary template Lindsay Mazotti, MD and C. Bree Johnston, MD for adaptation of elements of their presentation on transitional care Elements of Discharge Summary Presentation on Admission Chief Complaint History of Present Illness (HPI) PMH/Past Surgical History Emphasis should be on keeping this section succinct. 3-5 lines for HPI Discharge Summary cont. Medications on Admission Important to list in order to compare to discharge medications Admission Physical Exam Keep brief Focus on pertinent positives Pertinent Admission Labs and Diagnostic Studies Don’t list all labs! Hospital Course Should be the main focus of your discharge summary Should be divided by problem Focus on: Major acute problems Important chronic medical conditions (i.e., DM) Each problem should have only about one short paragraph Hospital Course For example, in a diabetic patient who presented with a stroke: Stroke: The patient was found to have no acute changes on non-contrast Head CT, and because he presented several hours after the onset of his symptoms, was only given aspirin on admission. Initially, he had a dense, flaccid, right hemiplegia with expressive aphasia. About five days into his admission, muscle strength improved to 3/5, and he was able to say some words and better understand language. Neurology consultants gave him a good prognosis for recovering most of his motor and language function. Hospital Course For example, in a diabetic patient who presented with a stroke: Diabetes: His glucose levels were difficult to control initially, with several random readings in the 300-400 level. Endocrine consult recommended increasing his Glargine Insulin dose, which helped fasting glucose levels return to the 100s. Hospital Course Even when divided by problem, within the sections should include: Consultations Treatments rendered with response Medication changes Pertinent new labs or diagnostic tests Procedures performed Complications Next Sections Code status/advance directives Was there communication with Primary Care Physician Disposition Important to specify new setting of care Include VNA, rehab, SNF, hospital transfer, or deceased Condition at Discharge Important to describe physical function and if there is a change from baseline Medications at Discharge Probably the most important section for accuracy. Medication errors are common pitfall of care transitions Important to highlight medicines that were stopped Highlight which medicines were changed, and which ones are new All images in this document provided by Lavanet.