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APPENDIXOFDICTATIONTEMPLATES
UndergraduateMedicalEducation
Approvedby:Clerkship&ElectivesCommittee
Dateoforiginalapproval: August,2013
Dateoflastreview: N/A
Dateofnextscheduledreview: August,2014
I. PURPOSE
Thefollowingdictationsamplesareincludedtoprovideclinicalclerkswithguidance.
II. DEFINITIONS
CTU ClinicalTeachingUnit
MRP MostResponsiblePhysician
PCCU PaediatricCriticalCareUnit
III. APPENDIX
CTU - Discharge Summary Dictation Template
All patients who 1) were admitted for seven or more days, and/or 2) had been admitted to the
PCCU (Paediatric Critical Care Unit), and/or 3) had a complex condition or complicated course in
hospital require a dictated (or typed) discharge summary.
1. Required initial information: Your name and position, most responsible physician (MRP) on
the day of discharge, patient’s first and last name, PIN, who
should receive this discharge summary (the MRP, the referring
physician if one is known, the paediatrician or family physician of
the patient (if not the referring physician), and other consultants
who are going to see the patient in follow-up.
Example: “This is John Smith, clinical clerk for Dr. X, dictating on
patient Getme Outofhere, PIN 00000000. Please forward copies
to Dr. X, Victoria Hospital, Dr. Y, family physician in London, Dr.
Z, Paediatrician in London.”
2. Most responsible diagnosis: Diagnosis primarily responsible for the patient’s current
admission.
3. History of present illness: Essential history of chief complaint as given by patient and/or
care providers. It should include a concise summary of the
relevant information from the time the symptoms started and up
to the arrival at the Emergency Department. In children with a
chronic disease of the organ system now acutely affected
include a one- or two-line summary of the underlying condition.
Do not describe other chronic issues here (see point 4.).
Example: “Sam X is a 9-month old boy with chronic lung disease
secondary to prematurity (27 weeks of gestation) on 0.5l of
oxygen at home. He presented to our Emergency Department on
July 1, 2010, with a 2-day history of increasing cough, increasing
oxygen requirements (from the usual 0.5l to 2l on the day of
presentation) and work of breathing, fatigue, and fever up to
38.9ºC.“