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.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
Patient Name: John DoeAge: 65Gender: MaleAdmission Date: 2023-10-01Discharge Date: 2023-10-10Summary 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 COPD2. Urinary tract infectionPlan 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.
Key advantages of using this template in clinical practice
Common questions about this template and its usage