Patient's Name and Medical Record Number:
Date of Admission:
Date of Discharge:
Attending or Ward Team Responsible for Patient:
Surgical Procedures, Diagnostic Tests, Invasive Procedures:
Brief History, Pertinent Physical Examination, and Laboratory Data:
Describe the course of the patient's disease up until the time that the patient came to the hospital, including physical exam and laboratory data. Hospital Course: Describe the course of the patient's illness while in the hospital, including evaluation, treatment, medications, and outcome of treatment.
Discharged Condition: Describe improvement or deterioration in the patient's condition, and describe present status of the patient. Disposition: Describe the situation to which the patient will be discharged
(home, nursing home), and indicate who will take care of patient. Discharged Medications: List medications and instructions for patient on taking the medications.
Discharged Instructions and Follow-up Care: Date of return for follow-up care at clinic; diet, exercise. Problem List: List all active and past problems. Copies: Send copies to attending, clinic, consultants.
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