Discharge Summary Template

Most Responsible Diagnosis (MRDx)
​The one diagnosis responsible for the longest portion of the length of stay and impacts care and treatment of the patient

Pre-Admit Diagnoses (Community Acquired)
Any diagnosis in addition to the MRDx that exists before or on admission and impacts length of stay, care and treatment of the patient

Post-Admit Diagnoses (Hospital Acquired)
Any diagnosis that arose after admission to hospital and impacts length of stay, care and treatment of the patient

Secondary Diagnoses (Medical History)
Other diagnoses that are important to communicate for continuity of care and do not impact current patient stay

Interventions
Operative and nonoperative procedures performed that contribute to hospital course

Flagged Interventions
If the following interventions listed below were performed, they must be documented
 
​Cardioversion​ECMO​Per-orifice ​Endoscopy
​Cell Saver​Endoscopic Percutaneous ​BiopsyPleurocentesis
​Chemotherapy​Feeding TubeRadiotherapy
​Central Lines​Heart Resuscitation​TPN
​(PICC/portacath)​Invasive Mechanical
Ventilation
​Tracheostomy
​DialysisParacentesis

Code Status
Indicate the status of the patient with respect to the desire for resuscitation

Relevant Consultants
Physicians that provide advice and/or treatment regarding the patient's condition

Allergies

​Identify known allergies of the patient


Medications on Discharge

​Details of discharge medications including reasons for giving or altering medications, frequency, dosage and proposed length of treatment


Post-Discharge Follow-up

​Instructions and specific plans after discharge including follow-up appointments with physicians and any further outpatient investigations


Discharge Disposition

​The location where the patient was discharged to (home, nursing home, transferred to another facility) or the status of the patient on discharge


Treatment and Course in hospital

​Brief summary of the management of each active medical problems during admission


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