Date of admission:
Date of discharge:
*start of dictation*

Discharge diagnosis: (1, 2, etc)
Other (non-active) dx:
Follow-up: (appts, pending ix, home care)
Discharge meds: (dose, freq, route, duration)
Summary of presenting illness:
• 1-2 line summary of presenting illness & reason for admission. Refer to separately dictated note for full hx & px of admission. Only if no admission dictation completed, indicate full HPI, PMH, and initial px prior to ‘Course in Hospital’
Course in hospital:
• Describe briefly the events and progression of illness while in hospital including status upon discharge
• If multiple medical issues, this section can be done by system (cardiovascular, respiratory, fluids and nutrition, ID, hematological, CNS, etc)
Operations performed in hospital:
Investigations in hospital:
• Include if any significant findings
Discharge plan:
• Who the patient is following up with
• Any issues the GP needs to follow up on
• Dressings (CCAC)
• Return to ER if..

Example
Date of admission: June 20, 2015
Date of discharge: June 30, 2015
Admission diagnosis:
1. Scald burn to bilateral thighs, TBSA = 15%
Discharge diagnosis:
1. Second degree scald burns to bilateral thighs, TBSA = 15%
2. Hypertension
Operations performed in hospital: Split thickness skin grafting left thigh June 23
History of presenting illness: Ms. X is a 65 yo F admitted to Hamilton General Hospital on June 22 after sustaining scald burns to her thighs from hot tea. She was transferred to our hospital from Brantford due to concerns of full thickness burns of TBSA 15%. She was admitted for monitoring and wound management as we suspected she may require skin grafting.
Course in hospital: It became apparent on the second day of admission that her left thigh burns were deep partial thickness and wound benefit from split thickness skin grafting to expedite healing. This procedure occurred on June 23, 2015. Post-operatively she was stable, though she was hypertensive throughout her admission with systolic pressures in the 180s. She was started on hydrochlorothiazide. The patient was kept in hospital until her dressings were manageable by CCAC on an outpatient basis.
Investigations in hospital: Routine bloodwork was unremarkable.
Discharge medications:
1. Hydrochlorothiazide 12.5 mg PO daily
2. Tylenol #3 x 40 tabs
3. Colace x 20 days
Discharge plan:
1. CCAC will be providing dressing changes q2days.
2. She will return for reassessment at the outpatient burn clinic on X day.
3. We kindly ask her family doctor, Dr. Y, to follow up on her hypertension and adjust her medications as necessary.