Dictate Discharge Summary

All Discharges Summaries are to be dictated within 48 hour of the patient’s discharge

IDENTIFY yourself clearly (first and last name), spell patient’s first and last name, and give the patient medical record number.

• Admission date
• Discharge date
• Attending Physician
  • FOR RESIDENTS: Please state “I am dictating for…” including physician’s first and last name. 
• Referring Physician
• Admitting Physician
• REASON FOR ADMISSION
  • Condition requiring inpatient status
• PATIENT PROFILE
  • Identify the patient regarding age, etc.
• FINAL DIAGNOSIS
  • Conditions found, after study, to be the reason for admission to the hospital. List all documented diagnosis.
  • Identify which conditions were present on admission. Do NOT use abbreviations in a diagnosis.
• PROBLEMS ARISING DURING HOSPITALIZATION
  • List additional diagnoses. Infections and/or complications integral to a procedure or treatment.
• PROCEDURES
  • Surgeries in and out of the OR, interventional and significant treatments/procedures. Do NOT use abbreviations in procedure name.
• MANAGEMNT OF PROBLEMS
  • Diagnostic findings, therapeutic approaches, and outcomes for significant problems addressed.
• PATIENT CONDITION AT DISCHARGE
• DISCHARGE INSTRUCTIONS
  • List medications. State instructions given to patient regarding follow-up, diet, level of activity, etc.