Table 3 Valuable elements of a discharge summary
| Admitting diagnosis |
| Final diagnosis |
| Admission and discharge date |
| Contact information |
|
- Primary care provider (name, phone, fax) - Hospital physician or resident - Specialists |
| Detailed patient history |
|
- Medical/surgical - Daily living (social, mobility) - Home environment |
| Course in hospital |
|
- Surgery: Concise summary including date of surgery, type of surgery and selection of anaesthesia; Preoperative care; Postoperative care and complications - Adverse events: procedures required (detailed); delirium, Date occurred; Management, Pertinent negatives - Other conditions impacting hospital stay (medical/surgical/social) - Goals of care: code status, advanced directives, - Functional status: behaviour, precautions or restrictions and participation at discharge (Include PT and OT documentation) - Cognitive function and assessments pre and post discharge |
| Falls |
|
- History of falls: frequency, mechanism - Details about the fall that precipitated fracture - Falls prevention recommendations |
| Bone health |
|
- Bone health investigations - Bone health management - Changes to osteoporosis medications – initiation, dosing and follow-up implications. |
| Consult services and recommendations |
|
- Rehabilitation therapists (details on consent, assessment and treatment) - Geriatric medicine, geriatric psychiatry, medical consults, anesthesia, etc |
| Summary of key results, investigations, summary of bloodwork to identify trends |
| Medication |
|
- Allergies - Medications reconciliation - Pain control - Venous thromboembolism prophylaxis - Osteoporosis treatment - Adherence: # of tablets |
| Post-discharge health management plan |
|
- Follow-up appointments (those made or to be made, including dates and times) - Health management plan and timelines – clear instructions to patient and primary care provider - Outstanding Investigations and pending results - Referrals and homecare supports - Projections and expectations on recovery - Discharge facility (unit and program) - Wound care instructions - Equipment required pre and post hospital discharge |
