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Discharge*Summary*
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Facility:* * * * * * * *
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Patient(Name:(( ( ( ( **DOB:*** * Date/Time:( ( ( *
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Date(of(Admission:((( ( ( ( ( Date(of(Discharge:((( ( ( ( (
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Discharge*Diagnosis:*
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Procedures(&(Therapies:(( ( ( ( ( ( ( ( (
Complications:((( ( ( ( ( ( ( ( ( (
Consultations:(( ( ( ( ( ( ( ( ( (
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Pertinent*History:**(( ( ( ( ( ( ( ( ( ( (
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Lab:**( ( ( ( ( ( ( ( ( ( ( ( ( *
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Condition(on(Discharge:((( ( ( ( ( ( ( ( ( ( (
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Disposition:*( ( ( ( ( ( ( ( (
Discharged(to:((( ( ( ( ( ( ( (
Diet:(( ( ( ( ( ( ( ( ( (
Activity:((( ( ( ( ( ( ( ( (
DME:(((( ( ( ( ( ( ( ( (
Home(Health(Services:((( ( ( ( ( ( (
Lab:((( ( ( ( ( ( ( ( ( (
F/U(apts.:((( ( ( ( ( ( ( ( (
Meds:(((
( Stop:( ( ( ( ( ( ( ( ( (
( Modify:((( ( ( ( ( ( ( ( (
( New(Rx:((( ( ( ( ( ( ( ( (
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Name:((( ( ( ( ( ( ( Fax(to:((( ( ( ( (
Charge: __99315 __99316