Discharge Summary General Format

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Discharge Summary: General Format
Patient Name:
Medical Record Number:
Admission Date:
Discharge Date:
Attending Physician:
Dictated by:
Primary Care Physician:
Referring Physician:
Consulting Physician(s):
Condition on Discharge:
Final Diagnosis:
(list primary diagnosis FIRST)
Procedures:
(list dates, complications)
History of Present Illness
(can refer to dictated/written HPI)
Laboratory/Data
(be BRIEF, just the most PERTINENT results that need to be followed)
(by PROBLEM LIST…. NOT BY DATE --- )
Hospital Course
(MOST IMPORTANT – LIST MEDS THAT ARE DIFFERENT FROM
Discharge Medications
ADMISSION MEDICATIONS)
Discharge Instructions
(diet, activity, discharged to home/nursing facility, etc)
Follow up Appointments
Code Status
Dictated by…

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