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Table 3 Valuable elements of a discharge summary

From: Design of an orthopaedic-specific 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