The discharge summary template from s10.ai is a vital resource for emergency medicine professionals, designed to meticulously document a patient's hospital journey and outline their post-discharge care plan. This comprehensive template features sections for the primary diagnosis, medical history, hospital course, any complications, discharge strategy, unresolved issues, and medications prescribed at discharge. It provides a thorough overview of the patient's condition and treatment, ensuring a smooth transition to outpatient care. By utilizing s10.ai, clinicians can efficiently complete this template, guaranteeing precision and uniformity in medical documentation. This tool is perfect for emergency medicine specialists aiming to optimize their discharge procedures.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
MOST RESPONSIBLE DIAGNOSISPneumoniaMEDICAL PROFILEHypertension, managed with medicationType 2 Diabetes, A1C 7.2, stableChronic Obstructive Pulmonary Disease (COPD), stable with inhalersCOURSE IN HOSPITALThe patient, a 68-year-old male, was admitted on 1 November 2024 with shortness of breath and fever. Initial evaluation indicated pneumonia, confirmed by chest X-ray. The patient was initiated on intravenous antibiotics and supplemental oxygen. Throughout the hospital stay, the patient exhibited gradual improvement in respiratory function. A significant improvement was noted on day 4 when the patient was able to maintain oxygen saturation above 92% on room air. Discharge was postponed due to a brief episode of atrial fibrillation, which was managed with medication.COMPLICATIONSAtrial fibrillationDISCHARGE PLAN- Continue oral antibiotics for 7 days- Follow-up with primary care physician in 1 week- Pulmonary rehabilitation referralISSUES PENDING AT DISCHARGE/TRANSFER- Awaiting results of sputum cultureMEDICATIONS AT DISCHARGE- Candesartan 32 mg P.O. daily, continued at same dose- Metformin 500 mg P.O. BID, continued- Salbutamol inhaler, as needed, continued- Amoxicillin 500 mg P.O. TID for 7 days, started in hospital- Metoprolol 25 mg P.O. BID, started in hospital for atrial fibrillation
Key advantages of using this template in clinical practice
Common questions about this template and its usage