The one diagnosis responsible for the longest portion of the length of stay and impacts care and treatment of the patient
Any diagnosis in addition to the MRDx that exists before or on admission and impacts length of stay, care and treatment of the patient
Other diagnoses that are important to communicate for continuity of care and do not impact current patient stay
Operative and nonoperative procedures performed that contribute to hospital course
If the following interventions listed below were performed, they must be documented
| Cardioversion | ECMO | Per-orifice |
| Cell Saver | Endoscopic Percutaneous | Endoscopy |
| Chemotherapy | Biopsy | Pleurocentesis |
| Central Lines | Feeding Tube | Radiotherapy |
| (PICC/portacath) | Heart Resuscitation | TPN |
| Dialysis | Invasive Mechanical Ventilation | Tracheostomy |
| | Paracentesis | |
Indicate the status of the patient with respect to the desire for resuscitation
Physicians that provide advice and/or treatment regarding the patient's condition
Identify known allergies of the patient
Details of discharge medications including reasons for giving or altering medications, frequency, dosage and proposed length of treatment
Instructions and specific plans after discharge including follow-up appointments with physicians and any further outpatient investigations
The location where the patient was discharged to (home, nursing home, transferred to another facility) or the status of the patient on discharge
Brief summary of the management of each active medical problems during admission