Patient Demographics
Patient Name:
Patient's Name
Patient Identifier (Medical Record Number):
Patient's hospital Medical Record Number (MRN)
Gender:
Patient's Gender
Visit (Encounter)
Admit Date:
Date of Admission
Discharge Date:
Patient's Date of Discharge
Discharge Diagnosis:
Diagnosis most responsible for the patient's course in hospital. If there is more than one such condition, the one held most responsible for the greatest portion of the length of stay or greatest use of resources
Discharge Disposition:
Location where the patient was discharged to. e.g. Home, Home with Support Services, Transfer to Other Institution (named) or Death
Diagnosis
Pre-existing/Developed Conditions Impacting Hospital Stay:
Condition(s) that coexist at the time of admission or developed post-admission and:
• Requires treatment, or
• Increases the length of stay by at least 24 hours (regardless of whether they were managed intensively during the stay (e.g. dementia), or
• Significantly affects the treatment received
Conditions Not Impacting LOS:
Pre-existing comorbidities or condition(s) that developed post-admission that did not affect the patient's length of stay
Course While in Hospital
Presenting Complaint(s):
Symptom(s) for which the patient initially sought treatment and presented with
Summary Course in Hospital:
Succinct summary of the patient's clinical course in hospital. Conclusion of associated investigation
Investigations:
Succinct summary of examinations and tests conducted while in hospital
Interventions (Procedures & Treatments):
Procedure(s) and/or treatments(s) carried out during course in hospital
Alert Indicators
Allergies:
If available, list all relevant allergies and describe reaction
Discharge Plan
All Medications at Discharge:
Home medications to be continued, home medications which have been adjusted or discontinued, and newly prescribed medications
Follow-up Instructions for Patient:
Follow-up instructions for patient, include follow-up scheduled appointments, if applicable
Follow-up Plan Recommended for Receiving Provider(s):
Investigations and interventions recommended to be conducted by the receiving provider after the patient has been discharged
Referrals:
Referrals that have been initiated by the sender
Copies to be sent to:
Other clinicians who are included in care of patient