Discharge Letter Templates printable pdf download

Discharge Letter Templates

Discharge Letter Example 1

Letter Date: xx/xx/xxxx

Reference:

Dictated Date: xx/xx/xxxx

Transcribed Date: xx/xx/xxxx

PATIENT; ………D.O.B:……..; CHI: ……….

Admission: Specialty -….; Ward – xx

Consultant: Date of Admission - xx/xx/xxxx

Date of Discharge - xx/xx/xxxx; Discharged to: [ . . ]Follow Up: [ ]

Clinical Comments:

Diagnosis: Musculoskeletal chest pain

Ischaemic heart disease

Type II diabetes mellitus

Hypertension

Previous CVA

Obesity

This [..] year old woman was admitted with a complaint of recurrent [chest pain].

There is a background of ischaemic heart disease with previous [. . ] myocardial

infarction and [. . . ]

Other history is of hypertension, cerebral vascular disease, type II diabetes mellitus

and obesity. Cardiac examination [ . . ] ECG showed sinus rhythm with old [. . ]

infarction. There were no sequential changes and troponin was not raised.

I felt that her symptoms were consistent with musculoskeletal origin. [ . . ].

Yours sincerely,

Dr [ . . ]

INFORMATION COMMENTS FOR CODING PURPOSES:

This is a good example of a very codeable discharge summary with a good patient

history identifying any relevant co-morbidities

Discharge Letter Templates