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DISCHARGE SUMMARY TEMPLATE
Approved by the Provincial HIM Leadership Committee March 19, 2010
DEMOGRAPHIC AND ADMINISTRATIVE DATA
PATIENT NAME
ADDRESS
CHART NUMBER
ACCOUNT NUMBER
(Meditech Registration Account Number)
HEALTH CARE NUMBER
DOB
GENDER
ADMISSION DATE
DISCHARGE DATE
REFERRING PHYSICIAN
MOST RESPONSIBLE PROVIDER (Attending physician)
FAMILY PHYSICIAN
ADMISSION DIAGNOSIS-
Working diagnosis at time of admission (Do not use abbreviations.)
MOST RESPONSIBLE DIAGNOSIS (MRDx)
The one diagnosis or condition that can be described as being most responsible for the
patient’s stay in hospital (Do not use abbreviations.)
PRE-ADMIT COMORBIDITY(IES)
A condition(s) that coexists at the time of admission (Do not use abbreviations.)
POST- ADMIT COMORBIDITY(IES)
A condition(s) that arises post-admission (Do not use abbreviations. )
SECONDARY DIAGNOSIS(ES)
A secondary diagnosis(es) or condition(s) which may or may not have received treatment but does
not impact on the patient’s LOS or treatment (Do not use abbreviations.)
INTERVENTIONS
Diagnostic and/or Therapeutic interventions performed during the current episode of care