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University Health Network Discharge Summary Template for Dictation
www.uhnmodules.ca/DischargeSummary/guides.html March 2016
UHN Discharge Summary Template
Your dictated Discharge Summary should follow the template below. Include headings as they are appropriate:
1. Patient (Demographics)
Patient Name
Patient's Name
Patient Identifier
Patient's hospital Medical Record Number (MRN)
Gender
Patient’s Gender
2. Visit (Encounter)
Admit Date
Date of Admission
Discharge Date
Patient’s Date of Discharge
Discharge Diagnosis
Diagnosis most responsible for the patient's course in hospital. If there is more
than one such condition, the one held most responsible for the greatest portion
of the length of stay or greatest use of resources
Discharge Disposition
Location where the patient was discharged to. e.g. Home, Home with Support
Services, Transfer to Other Institution (named) or Death
3. Diagnosis
Pre-existing / Developed
Conditions Impacting Hospital
Stay
Patient condition(s) that coexist at the time of admission or developed post-
admission and:
• Requires treatment, or
• Increases the length of stay by at least 24 hours (regardless of whether they
were managed intensively during the stay, e.g. dementia), or
• Significantly affects the treatment received
Conditions Not Impacting LOS
Pre-existing comorbidities or condition(s) that developed post-admission that
did not affect the patient's length of stay
4. Course While in Hospital
Presenting Complaint(s)
Symptom(s) for which the patient initially sought treatment and presented
with
Summary Course in Hospital
Succinct summary of the patient’s clinical course in hospital. Conclusion of
associated investigation
Investigations
Succinct summary of examinations and tests conducted while in hospital
Interventions
Procedure(s) and/or treatments(s) carried out during course in hospital
5. Alert Indicators
Allergies
If available, list all relevant allergies and describe reaction
6. Discharge Plan
All Medications at Discharge
Home medications to be continued, home medications which have been
adjusted or discontinued, and newly prescribed medications
Follow-up Instructions for
Patient
Follow-up instructions for patient, including follow-up scheduled
appointments, if applicable
Follow-Up Plan Recommended
for Receiving Provider(s)
Investigations and interventions recommended to be conducted by the
receiving provider after the patient has been discharged
Referrals
Referrals that have been initiated by the sender
Copies to be Sent to
Clinicians other than Primary Care/Referring Provider