Discharge Note

CHIEF COMPLAINT:    
Reason for    presentation
Display the patient’s symptoms that caused a visit to the hospital

PRINCIPAL DIAGNOSIS:
Display the diagnosis that caused a visit to    the hospital

When a diagnosis has not yet been made, the most granular clinical concept with
the highest level of certainty should be displayed. This may be a problem, symptom,
sign, or test result, and may evolve over time, as a conventional diagnosis is
reached. For example, ‘dyspepsia’ may be the diagnosis when a patient first
presents with indigestion, upgraded to ‘gastric ulcer’ when this is found at
endoscopy, and ‘gastric cancer’ when biopsies reveal this

SECONDARY DIAGNOSES
the list of problems and diagnoses    (in addition to the principal diagnosis) that    were treated at hospital  

COMPLICATIONS
Display any additional patient conditions    or any adverse events that affected the    hospital treatment

COMORBIDITIES:
any previous patient conditions
that are relevant to the treatment provided    at the hospital, and are important for the    primary healthcare provider to be aware 


RELEVANT    PROCEDURES/OPERATIONS:
Display procedures immediately
after problems and diagnoses.
List the procedures and
interventions in chronological
order.
If no procedures were performed
during the hospital stay, include
the statement ‘Nil performed`.

All procedures undertaken should be included in the e-discharge summary, including:
diagnostic as well as therapeutic procedures and therapies
medical as well as psychological procedures and therapies (e.g. cognitive
behaviour therapy; follow-up interventions as a result of physical health checks)
procedures carried out on different days during the hospital stay.
complementary or alternative procedures and therapies

Outcomes or results of procedures should be recorded in the ‘comments’ field, as well
as a comment to clarify such as statement that information is partial or incomplete

The discharge summary should include the operation which was actually carried out,
not the planned procedure, as this may have been changed. The detail should be
taken from the record of the actual procedure (e.g. operating note) rather than the
planned procedure (e.g. consent to treatment).
The procedure, anatomical site and laterality should be noted    wherever possible
There are specific elements for complications relating to the procedure and
anaesthetic issues

The anaesthesia issues included could be, for example, “short neck, difficult to
intubate” and the actual intubation grade or adverse reactions.
All those
deemed to be clinically important for future care should be listed. 

Participation in research
This section should be used to flag participation in clinical trials or other research initiatives.
When a patient is enrolled on a drug trial/ intervention, the GP receives detailed information
from the research sponsor. To avoid duplication the discharge summary need contain the
following information only:
• Drug/intervention name
• Trial name (and URL if possible)
• Whether the patient is currently involved in a trial.

HISTORY OF PRESENT ILLNESS:
Tell a chronological history of the illness to this date.

PROBLEM LIST

DIAGNOSTICS
Only important or relevant results should be included, ie those that the clinician wants
to communicate. This is to reduce the risk of overload of irrelevant information

It is important to record why test have been done and where relevant, who is going to
follow up (i.e. GP or hospital). Follow up should be recorded in the plan and requested
actions section.

Investigations carried out where results are not yet available should be recorded in
this section.

RELEVANT    LABS
RELEVANT    IMAGING
RELEVANT    PROCEDURES
RELEVANT    PATHOLOGY
OTHER    RELEVANT     TESTS

HOSPITAL COURSE/CLINICAL    SUMMARY

Tell a chronological history of the management to this date.

Use line breaks to separate topics

Use bullet points or short
sentences where appropriate,
rather than full paragraphs

Use bold letters and coloured font
to highlight critical information

Avoid abbreviations

Avoid repeating information that    occurs in other sections of the discharge summary, such as medicines and investigations

Ensure this section is succinct    but also provides all the relevant
information

Describe abnormal investigation
results in this section

This section should give the    healthcare provider all the relevant information to    continue treating the patient outside the    hospital

CONSULTANTS
This is the treatment plan, following discharge, for the treating teams and clinicians
and any actions requested. The plan should make clear who is expected to take
responsibility for actions following the encounter, eg the person receiving care or their
carer; the GP or another heath care professional. For example, follow up renal
function test to be arranged by the GP within two weeks of appointmen

DISPOSITION


CONDITION ON DISCHARGE
DISCHARGE ACTIVITIES:
VITALS:
DISCHARGE MEDICATIONS:

DISCHARGE    DEVICES:
PATIENTS FOLLOW UP CARE REQUIRED:
PCP
URGENT ISSUES TO BE FOLLOWED UP BY THE PRIMARY CARE TEAM:
include specific dosages, duation and frequencies
In some instances health care professionals may want to communicate to the GP
specific information and advice which was given to the patient. It is important that this
is concise and is only information which it is pertinent for the GP to be aware of.
Alerts
Display alerts as a bullet list, using
short sentences

Include a list of alerts that may
affect the patient’s continuity of
care

Display recommendations
immediately after alerts

Describe the recommended action

Name the person responsible for
actioning the recommendation

Clearly describe the
recommendation, including any
relevant timeframes

If investigation results are
pending at the time of discharge,
include a recommendation for
the relevant healthcare provider
Name the person responsible for
actioning the recommendation


When a diagnosis has not yet been made, the most granular clinical concept with
the highest level of certainty should be displayed. This may be a problem, symptom,
sign, or test result, and may evolve over time, as a conventional diagnosis is
reached. For example, ‘dyspepsia’ may be the diagnosis when a patient first
presents with indigestion, upgraded to ‘gastric ulcer’ when this is found at
endoscopy, and ‘gastric cancer’ when biopsies reveal this