Discharge Letter Templates (Page 2 of 7) in pdf

Discharge Letter Templates Page 2

Discharge Letter Example 2

Letter Date: xx/xx/xxxx

Reference:

Dictated Date: xx/xx/xxxx

Transcribed Date: xx/xx/xxxx

PATIENT; ………D.O.B:……..; CHI: ……….

Admission: Specialty -Opthalmology Ward – xx

Consultant: Date of Admission - xx/xx/xxxx

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

Clinical Comments:

Procedures – Insertion of prosthetic replacement of lens NEC

Phakoemulsification of lens

Clinical Comments:

Diagnosis:

Cataracts

Diabetes

[ . . ]

Treatment: Right phaco and IOL under local anaesthesia

Treated: xx/xx/xxxx

Yours sincerely,

Dr [ . . ]

INFORMATION COMMENTS FOR CODING PURPOSES:

This summary provides precise procedure information made available for coding

purposes. It is worth pointing out that there are codes available to specifically code

diabetic cataracts however a coder will not assume that the cataracts are due to

diabetes unless a clinician specifically states diabetic cataracts in the clinical

information. In this example therefore you would not code diabetic cataracts as there

is nothing in the information to state that the association is causal even though the

patient has diabetes.

Discharge Letter Templates Page 2