Discharge Letter Templates (Page 3 of 7) in pdf

Discharge Letter Templates Page 3

Discharge Letter Example 3

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: [ ]

Diagnosis: Syncope and collapse

Follow Up: [ ]

Clinical Comments:

Diagnosis: 1. Likely vasovagal episode 2 . Type II diabetes mellitus 5. Minor

atelectasis of [. . ] 6. Incidental [ . . ] 7. Macular degeneration 8. CKD

Medications on discharge: As per the immediate discharge summary

I saw this [ . . ] year old lady on the day of admission who came in with a history of

blackout [ . . ]. She had a background of type II diabetes mellitus. There was no [ . . ].

Her 12 lead ECG showed [ . . ]. She had a negative troponin after admission. Her D

dimer was [ . . ]. She underwent a CTPA which did not show any clot however there

was some suggestion of atelectasis [ . . ]. Yours sincerely,

Yours sincerely,

Dr [ . . ]

INFORMATION COMMENTS FOR CODING PURPOSES:

Appears to be a good summary with lots of information on comorbidites and other

additional findings included. However from a coding perspective there is a bit of

conflicting information. Coders would not normally code anything which began with

‘suggestion of’. In this case the information was also included in the diagnosis and

so it would be reasonable to code. The term ‘likely’ was also used. In this case we

would also code as present.

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