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Specialist In Internal Medicine
5-10 minutes

Summary of Hospital Discharge

The Hospital Discharge Summary template is a vital resource for internal medicine specialists, designed to meticulously document a patient's clinical journey and deliver precise follow-up care instructions at discharge. This template enables healthcare professionals to concisely summarize treatment strategies, key events, and any changes in the patient's condition during their hospital stay. It also incorporates follow-up guidance and educational resources to maintain seamless continuity of care. When integrated with s10.ai, the AI medical scribe, this template significantly enhances the discharge process by ensuring thorough and precise documentation. This tool is perfect for internal medicine specialists and other healthcare providers engaged in patient discharge planning, encouraging them to adopt, explore, or implement this efficient solution.

1,484 uses
4.1/5.0
J
Jonathan Carter
Template Structure

Organized sections for comprehensive clinical documentation

(You are to compose a discharge summary for a patient)
[Outline the patient's clinical journey since admission, detailing treatment methods, significant events, condition changes, or interventions in a narrative format] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Offer follow-up guidance and education] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(Never create your own patient details, assessment, plan, interventions, evaluation, and plan for ongoing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note.)
Sample Clinical Note

Example of completed documentation using this template

Patient Name: John Doe
Age: 65
Gender: Male
Admission Date: 2023-10-01
Discharge Date: 2023-10-10
Summary of Clinical Course:
Mr. John Doe was admitted to the hospital on October 1, 2023, due to an acute flare-up of chronic obstructive pulmonary disease (COPD). Upon arrival, he was administered bronchodilators and corticosteroids. His condition showed improvement with the treatment, and he was able to discontinue supplemental oxygen by October 5, 2023. On October 7, 2023, he developed a slight fever and was diagnosed with a urinary tract infection, which was managed with antibiotics. His condition stabilized, and he was considered ready for discharge on October 10, 2023.
Follow-up Advice and Education:
Mr. Doe is advised to continue using his prescribed inhalers and to have a follow-up appointment with his primary care physician in two weeks. He should keep an eye on his symptoms and seek medical help if he experiences worsening shortness of breath or fever. Support for smoking cessation was provided, and he is encouraged to participate in pulmonary rehabilitation sessions.
Discharge Medications:
1. Albuterol Inhaler - Use as needed for shortness of breath.
2. Prednisone 10 mg - Take once daily for 5 days.
3. Ciprofloxacin 500 mg - Take twice daily for 7 days.
Discharge Diagnosis:
1. Acute exacerbation of COPD
2. Urinary tract infection
Plan for Continuing Care:
Mr. Doe will continue his COPD management plan and attend follow-up appointments as scheduled. He is encouraged to maintain a healthy lifestyle and adhere to his medication regimen.
Clinical Benefits

Key advantages of using this template in clinical practice

  • The Discharge Summary Template is an essential tool for healthcare professionals seeking to streamline patient transitions from hospital to home or another care setting. This comprehensive template is designed to capture the patient's clinical course since admission, detailing treatment methods, significant events, and any changes in condition or interventions. It ensures that all critical information is documented in a clear, narrative format, enhancing communication among care teams and supporting continuity of care. Additionally, the template provides sections for follow-up advice and patient education, ensuring that patients and their families are well-informed about the next steps in their care journey. By adopting this template, clinicians can improve patient outcomes, reduce readmission rates, and enhance overall care coordination. Explore the Discharge Summary Template today to optimize your clinical documentation process.
Frequently Asked Questions

Common questions about this template and its usage

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Summary of Hospital Discharge