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RE CHF: For each, be sure to clarify: □ What the problem is: Diagnosis, severity and prognosis (if relevant) □ Plans for managing problem: o Current therapies Planned therapies Planned/Pending investigations What has been discussed with the patient/family (Goals of Care, resuming activities, lifestyle changes, monitoring issues (sugars, daily weights etc.) and prognosis (when relevant ) Who will provide follow-up, what they will be doing and why for example: “Because of the risk of hyperkalemia and worsening renal dysfunction, we have asked the family doctor to re-check electrolytes in two weeks” For things you expect others to do, ask the transcriptionist to “Bold that” Also be sure to indicate: o Disposition (nursing home etc.) o Services arranged (CCAC etc.) Abbreviated Dictation Format Introduction: Identify self, role, date, patient name, PIN and their D.O.B.. Re Diabetes:) • State final opinion of what problem is • Plans for managing problem: - Current/Planned therapies - Planned/Pending investigations - What patient/family have been told - Who will provide follow-up and what they will be doing Also indicate: - Disposition (nursing home, home etc.) - Services Arranged (home care etc.) Gynaecology – New Consult LONDON HEALTH SCIENCES CENTRE VICTORIA HOSPITAL Surname, Given Name PIN: 1234 56 78 DOB: 1958/05/31 Copy for: Dr. Akhtar, Saima CONSULTATION cc: Dr. Saima Akhtar, VH 1234 56 78 Dr. J.. Sincerely, Saima Akhtar, MD, FRCSC Department of Obstetrics Gynecology D: April 21, 2010 T: April 23, 2010 SA/bb Job No: 2634965/1776188 Akhtar, Saima MD, FRCSC Signed on: 2010/05/03 17:26 Akhtar, Saima MD, FRCSC Authenticated on: 2010/05/03 17:28 Gynaecology – Discharge Summary Sample: Discharge Summary (Gynecology) Discharge Summary Surname, Given Name – 1234 56 78 Preliminary Report Result type: Discharge Summary Result date: April 30, 2010 Result status: transcribed Result Title: DISCHARGE SUMMARY Performed by: Jones, Jane on May 4, 2010 16:38 Encounter in
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