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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