Patient Discharge Summary
PATIENT DISCHARGE SUMMARY
Hospital: [HOSPITAL NAME]
Department: [DEPARTMENT]
Patient Name: [PATIENT'S FULL NAME]
Patient ID: [PATIENT ID]
Admission Date: [ADMISSION DATE]
Discharge Date: [DISCHARGE DATE]
Attending Physician: [NAME]
I. Introduction
This document provides a comprehensive overview of [PATIENT'S FULL NAME]'s hospital stay, from admission through discharge, documenting all relevant medical treatments and care provided. It also outlines detailed post-discharge care instructions and follow-up recommendations.
II. Reason for Admission
Primary Diagnosis: [PRIMARY DIAGNOSIS]
Secondary Diagnoses: [LIST ANY SECONDARY DIAGNOSES]
Symptoms at Admission: [LIST MAJOR SYMPTOMS THAT LED TO HOSPITALIZATION]
III. Treatment Summary
-
Surgical Procedures
|
Procedure Name |
Date |
Outcome |
|
[PROCDURE NAME] |
[DATE OF PROCEDURE] |
Successful, no complications |
-
Medication Administered
|
Medication |
Dosage |
Duration |
|
[MEDICINE 1] |
[DOSAGE] |
[DURATION] |
|
[MEDICINE 2] |
[DOSAGE] |
[DURATION] |
-
Other Treatments
Physical Therapy: Initiated to enhance mobility and aid recovery post-surgery.
IV. Hospital Course and Response to Treatment
Progress Overview: The patient showed consistent improvement and responded positively to the surgical procedure and subsequent treatments. Minor complications like post-surgical nausea were effectively managed.
V. Discharge Condition
-
General Condition: Stable and improved, cleared for home care.
-
Diet: Soft foods for 48 hours, then gradual return to normal.
-
Activity: Avoid strenuous activities for 2 weeks; light walking encouraged.
-
Medications: Prescribed continuing Amoxicillin and Ibuprofen as needed.
VI. Discharge Instructions
Home Care Instructions
-
Wound Care: Keep the surgical area clean and dry; watch for signs of infection.
-
Hydration and Diet: Maintain adequate hydration and adhere to the dietary guidelines provided.
Safety Measures
-
Mobility: Use assistance for walking until fully mobile to prevent falls.
-
Contact Information
-
Hospital Contact: [HOSPITAL PHONE NUMBER]
-
Primary Care Physician: [NAME], [PCP'S PHONE NUMBER]
VII. Follow-Up Care
|
Type |
Provider |
Date |
Purpose |
|
Post-Surgical Check |
[NAME] |
[DATE] |
Assess surgical recovery |
|
Routine Check-Up |
[NAME] |
[DATE] |
General health assessment |
VIII. Conclusion
This summary serves as a vital document ensuring continuity of care by providing a detailed account of [PATIENT'S FULL NAME]'s treatment and recovery process. It aids in the smooth transition from hospital care to home recovery and is essential for future medical consultations or in case of emergency. All parties involved in the patient's care have a clear understanding of the treatment history and post-discharge care instructions, promoting effective and informed ongoing care.
Summarized By: [YOUR NAME]
