Discharge Summary

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Physician Discharge Summary

Patient ID:

@NAME@

@MRN@

@AGE@ @SEX@

@DOB@

Admit date: @ADMITDT@

Discharge date and time: @EDTD@ @NOW@

Admitting Physician: @ATTPROV@

Discharge Physician: @ATTPROV@ 

Admission Diagnoses: @ADMITDX@

Discharge Diagnoses: @ADMITDX@

Admission Condition: Poor

Discharged Condition: Stable

Indication for Admission: @ADMITDX@

Hospital Course: 

The patient presented to UMCNO on @ADMITDT@ after sustaining trauma. The patient was found to have    and was admitted to the ICU. The patient recovered uneventfully and was  discharged in stable condition with follow up instructions. 

Consults: PT/OT

Significant Diagnostic Studies: 

CT scans, see radiology report

Treatments: 

Surgery

Discharge Exam: Patient doing sufficiently well to follow up as outpatient, please see morning progress note for exam.

Disposition: @MRDDSPOCOMMENT@

Patient Instructions: 

Activity: Activity as tolerated

Diet: Adult regular diet

Wound Care: Keep wounds clean and dry

@DISCHARGEMEDS@

Signed:

@MEMD@

@EDTD@

@NOW@