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Inova Fairfax Hospital Department of Medicine
Suggested Discharge Summary Format
(Modified from OU-Tulsa Department of Internal Medicine)
Principal discharge diagnosis (reason for hospital stay after hospital assessment)
Other discharge diagnoses which were addressed during hospital stay (Complete list of
active problems addressed during hospital stay)
Consultations: (name and specialty)
Procedures: (Name of procedure and concise description of results, only major studies)
Complications (for primary and other discharge diagnoses):
History and Hospital Course:
A concise summation of clinical course. Begins from time of admission with a brief summary (one paragraph) of key
data from H&P. Then, use a problem-oriented approach by writing a separate paragraph for each problem title
followed by a short synopsis of the evaluation, treatment and progress of each problem. Problems should match
diagnosis above. Must describe to what the problem was attributed, the intervention(s) which occurred and the
Avoid a laundry list of lab values: For example, simply say, “Chest X-Ray was unremarkable; CBC, serum
chemistries, were normal with the exception of elevated potassium of 6.3.” Do include lab values that will be of use in
clinic follow-up – e.g. HbA1C, lipid profile, TSH. Results of procedures documented under “procedures” can be
referred to and do not need to be repeated.
Condition upon discharge:
Date of next appointment and physician who will see patient
Medications at discharge:
Do not simply state “resume home medications.”
Issues to be addressed at follow-up:
CC: Please instruct transcriber to cc all physicians who will follow up with the patient, especially the PCP.
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