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METROPOLITAN HOSPITAL CENTER Department of Medicine/Division of Geriatrics Discharge Summary Template Make sure your patient is PRIMED for discharge! Primary diagnosis -Secondary diagnoses Return to: List clinics and appointment times Name and contact information of PCP Inpatient hospital course: Key findings and results Procedures Complications Condition at discharge (including functional and cognitive status) Medication reconciliation All medications patient is to take after discharge New medications and indications Discontinued medications and why they were discontinued If prescribing antibiotics, the start and end dates Exams and Expertise: What needs to be followed after discharge Labs Studies Consult recommendations Destination and DNR status: Home versus rehab (include name of facility and contact information) Code status and advance directives Tips on Improving Transitions of Care READY your patient for discharge! Referring and Receiving providers: -Contact providers at the time of admission and give providers a copy of the discharge summary at the time of discharge Educate: -Determine patient and caregiver knowledge about the current medical condition, medications, and plan of care -Provide written educational materials in patient’s preferred language and educational level -Use teach-back method Anticipate needs: -Assess patient and caregiver’s financial and social needs at the time of admission -Assess patient’s ability to perform activities of daily living at the time of admission and reassess before discharge -Make appropriate and timely referrals to consultants, social work, physical therapy, occupational therapy, and homecare Discharge summary and Drugs -Have a complete and accurate discharge summary on the day of discharge -Reconcile medications: Have patient’s family bring all medication bottles from home to review with you Only provide prescriptions for medications that the patient does not already have Review and update the prescriptions on the electronic medical record Be careful with hospital formularies and brand name medications-do not let patient get duplicate medications at the time of discharge Give enough medications to last until patient sees the primary care provider Your contact information -Give patient a phone number to call with questions occurring after discharge Card developed by Sophie Lin, M.D.
