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Most discharge letters include a section that summarises the key information of the patient's hospital stay in patient-friendly language, including investigation results, diagnoses, management and follow up.
Start ? consultants name at the top (they take ultimate medicolegal responsibility for the patient's care). Patient Details. Which ward (and department) ... Diagnoses. Current diagnosis. ... Management (procedures, operations, treatments, referrals) ... Discharge drug list. ... Follow-up plan. ... Action for GP or patient.
Additional Hospital Discharge Summary Recommendations emergency plan and contact number and person; treatment and diagnostic plan; prognosis and goals of care; advance directives, power of attorney, consent; planned interventions, durable medical equipment, wound care, etc.; assessment of caregiver status; and.
6 Components of a Hospital Discharge Summary Reason for hospitalization: description of the patient's primary presenting condition; and/or. ... Significant findings: ... Procedures and treatment provided: ... Patient's discharge condition: ... Patient and family instructions (as appropriate): ... Attending physician's signature:
Essential elements of written discharge instructions Patient name. Physician name. Purpose of discharge instruction. Diagnosis/expected course. Potential complications. Patient instruction.