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Table 4 Discharge summary template elements

From: Design of an orthopaedic-specific discharge summary

Patient demographics

Patient name, MRN

Date of birth

Gender

Primary care provider

Visit

Admit date

Discharge date

Most responsible health care provider name and contact information

Name of individual completing summary

Date completed

Discharge location

Death (yes, no)

Encounter location

Hospital name

Hospital type

Alert indicators

Allergies

Course while in hospital

Presenting complaint(s)

Summary of key results, investigators, interventions, and advance directives

Adverse events and complications

Discharge plan

All medications at discharge

Follow-up instructions for patient

Follow-up plan recommended to be implemented by the receiving provider

Referrals

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