Discharge Letter Templates (Page 5 of 7) in pdf

Discharge Letter Templates Page 5

Discharge Letter Example 5

Letter Date: xx/xx/xxxx

Reference:

Dictated Date: xx/xx/xxxx

Transcribed Date: xx/xx/xxxx

PATIENT; ………D.O.B:……..; CHI: ……….

Admission: Specialty -Orthopaedics….; Ward – xx

Consultant: Date of Admission - xx/xx/xxxx

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

Clinical Comments: Ms [ . . ] was admitted under Mr [ . . ] after sustaining an injury

to her left index finger. No fracture was seen on xray.

Yours sincerely,

Dr [ . . ]

INFORMATION COMMENTS FOR CODING PURPOSES:

In this example there is no information about the type of injury or how it happened.

This patient actually had an open would (laceration) with injury to the tendon (as

verified at a later clinic appontment). There was also a repair procedure carried out

at that time but this was not included in the discharge summary and would not be

captured in national statistics. From an injury prevention perspective it would also

have been useful to know how the injury had been sustained so that this information

could be coded

Discharge Letter Templates Page 5