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Discharge Summary (Template)
Check patient’s name, medical record number, date of birth, date of
admission, date of discharge, most responsible physician (MRP), referring
physician name.
FINAL DISCHARGE DIAGNOSIS
• Often only one diagnosis is responsible for admission (i.e. vasoocclusive
crisis, asthma exacerbation, bronchiolitis or Kawasaki
Disease)
• However sometimes there are associated diagnoses (i.e. Gastroenteritis
with dehydration and renal failure, osteomyelitis with bacteremia)
OTHER DIAGNOSIS (nonactive
or those affecting hospital stay)
Other diagnoses requiring treatment during hospitalization or underlying
medical diagnoses existing prior to admission
HISTORY OF PRESENTING ILLNESS
(Name) is a (year old) (sex) [who is previously healthy] or [with a past
medical history of XYZ] who presented with (X) day history of (summary
of pertinent positive and negative symptoms on history and other
relevant/contributing elements of birth history, development, past
investigations/treatment, immunizations as appropriate). Significant
signs on initial physical examination included__________. In the ER,
management included _______________.
COURSE IN HOSPITAL
(Name) was admitted to (name of service and ward)… [and describe
briefly the events and progression of illness while in hospital including
results and management. If the child has multiple medical issues, this
section can be done by system (cardiovascular, respiratory, fluids and
nutrition, ID, CNS, etc). List significant/complex investigations (with
results) under a separate heading.
At discharge, describe current symptoms, physical examination and
pending results.
DISCHARGE MEDICATIONS
Drug name, dose, route, dosing interval frequency, and duration
DISCHARGE GENERAL INSTRUCTIONS AND FOLLOWUP
All discharge summaries must include at least 3 essential elements
1. Discharge treatment plan including duration
2. Follow‐up with primary care physician in… (specify a reasonable time
frame)
3. Seek medical attention if…
May include other referrals and follow‐up appointments as necessary,
pending investigations and other community resources
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Documentation
t? PLAN (P) 1. Issue (1) 􀃆 plan (e.g., UTI on Day 2 of Empiric Abx, likely 14 day course required, await urine C&S) 2. Issue (2) 􀃆 plan 3. Issue (3) 􀃆 plan 4. Disposition – plans for home, transfer <span>Discharge Summary (Template) Check patient’s name, medical record number, date of birth, date of admission, date of discharge, most responsible physician (MRP), referring physician name. FINAL DISCHARGE DIAGNOSIS • Often only one diagnosis is responsible for admission (i.e. vasoocclusive crisis, asthma exacerbation, bronchiolitis or Kawasaki Disease) • However sometimes there are associated diagnoses (i.e. Gastroenteritis with dehydration and renal failure, osteomyelitis with bacteremia) OTHER DIAGNOSIS (nonactive or those affecting hospital stay) Other diagnoses requiring treatment during hospitalization or underlying medical diagnoses existing prior to admission HISTORY OF PRESENTING ILLNESS (Name) is a (year old) (sex) [who is previously healthy] or [with a past medical history of XYZ] who presented with (X) day history of (summary of pertinent positive and negative symptoms on history and other relevant/contributing elements of birth history, development, past investigations/treatment, immunizations as appropriate). Significant signs on initial physical examination included__________. In the ER, management included _______________. COURSE IN HOSPITAL (Name) was admitted to (name of service and ward)… [and describe briefly the events and progression of illness while in hospital including results and management. If the child has multiple medical issues, this section can be done by system (cardiovascular, respiratory, fluids and nutrition, ID, CNS, etc). List significant/complex investigations (with results) under a separate heading. At discharge, describe current symptoms, physical examination and pending results. DISCHARGE MEDICATIONS Drug name, dose, route, dosing interval frequency, and duration DISCHARGE GENERAL INSTRUCTIONS AND FOLLOWUP All discharge summaries must include at least 3 essential elements 1. Discharge treatment plan including duration 2. Follow‐up with primary care physician in… (specify a reasonable time frame) 3. Seek medical attention if… May include other referrals and follow‐up appointments as necessary, pending investigations and other community resources Handover At Sick Kids, IPASS is the format used for handover. • Illness severity o Stable / Watcher / Unstable • Patient Summary o Summary state


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