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1. Doctor discharge letter template full#
2. Doctor discharge letter template code#
3. Doctor discharge letter template professional#

A chest X-ray demonstrated bilateral pleural effusions, with evidence of upper lobe diversion.” An ECG showed evidence of left-ventricular hypertrophy and echocardiography revealed grossly impaired ventricular function (ejection fraction 35%). Include salient investigations performed during the patient’s admission: There was also a significant degree of lower limb oedema extending up to the mid-thigh bilaterally.” Clinical examination revealed reduced breath sounds and dullness to percussion in both lung bases. On arrival, she was tachypnoeic and hypoxic (oxygen saturation 82% on air).

Include a focused summary of the patient’s presenting symptoms and signs: home, residential care home)Ĭlinical details Presentation History and examination findings Discharge destination: destination of the patient on discharge from hospital (e.g.Date and time of admission and discharge.Discharging specialty/department: the specialty/department responsible for the patient at the time of discharge.Discharging consultant: the consultant responsible for the patient at the time of discharge.This section should encompass the salient aspects of the patient’s discharge:

Doctor discharge letter template code#

GP practice identifier: a national code which identifies the practice.GP practice details: name, address, email, telephone number and fax of the patient’s registered GP practice.This section should be completed with the details of the General Practitioner with whom the patient is registered: Next of kin/emergency contact: full name, relationship to the patient and contact details.Ethnicity: ethnicity as specified by the patient.Gender: the gender the patient identifies with.Patient sex: sex at birth (this determines how the individual will be treated clinically).Patient address: the usual place of residence of the patient.

Doctor discharge letter template full#

Patient name: full name of the patient (also the patient’s preferred name if relevant).Important information to include regarding the patient includes: You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation. In addition, different hospitals have different criteria to be included and you should always follow your hospital’s or medical school’s guidelines for documentation. As such, not all information included in this guide is relevant and needs to be mentioned in each discharge summary. In practice, each summary is adapted to the clinical context. Each section illustrates key pieces of information that should be included and aims to explain the rationale behind each part of the document. It gives a detailed description of each section that may be included in a typical discharge summary.

This guide will help you to understand what’s necessary to include and give you a structure to effectively write discharge summaries. Delays in the completion of the discharge summary are associated with higher rates of readmission, highlighting the importance of successful transmission of this document in a timely fashion. It is considered a legal document and it has the potential to jeopardize the patient’s care if errors are made. It is often the primary mode of communication between the hospital care team and aftercare providers.

Doctor discharge letter template professional#

A discharge summary is a clinical report prepared by a health professional at the conclusion of a hospital stay or series of treatments. An essential part of this process is the documentation of a discharge summary. Discharging patients from a hospital is a complex task.