Common Format for Dictating the Hospital Discharge Summary

Common Format for Dictating the Hospital Discharge 
tl Identify dictator
State that discharqe summary is being dictated
• State patient’s name, spelling out last name
• Give patient’s medical record (hospital) number
• State date(s) of hospital admission and discharge
• State final diagnosis(ses)
• Give patient’s chief complaint on admission
• Describe history of illness or problem requiring surgery
• list any significant findings on history and on physical,
radiographic, and laboratory examination
• Brieflydescribe hospital course, including the following:
• Description of all therapy rendered
• Any complications that occurred
• Outcome of any therapy provided
iii Describe discharge instructions given to the patient,
including the following:
• Disposition (to where ‘and with whom the patient is
being discharged) .
• Medications
• Activity
• Diet
• Hygiene
• Follow-up plans
• Describe patient’s condition on discharge
• Reidentify dictator
• State to whom copies of the summary should be sent