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    Hospital Patient Chart Free PDF Download PDF

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    nila nuril
    This document is a template for a preliminary discharge summary. It includes fields for patient information like name, chart number, and address. It also includes fields for admission and discharge details like date, attending physician, diagnoses, discharge disposition, predicted and actual length of stay. The template includes sections for documenting the patient's course in the hospital day-by-day, medications and activities on discharge, follow up appointments, and spaces for physician signatures.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Hospital Patient Chart Free PDF Download PDF

    Uploaded by

    nila nuril
    847 views1 page
    This document is a template for a preliminary discharge summary. It includes fields for patient information like name, chart number, and address. It also includes fields for admission and discharge details like date, attending physician, diagnoses, discharge disposition, predicted and actual length of stay. The template includes sections for documenting the patient's course in the hospital day-by-day, medications and activities on discharge, follow up appointments, and spaces for physician signatures.

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    This document is a template for a preliminary discharge summary. It includes fields for patient information like name, chart number, and address. It also includes fields for admission and discharge details like date, attending physician, diagnoses, discharge disposition, predicted and actual length of stay. The template includes sections for documenting the patient's course in the hospital day-by-day, medications and activities on discharge, follow up appointments, and spaces for physician signatures.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    847 views1 page

    Hospital Patient Chart Free PDF Download PDF

    Uploaded by

    nila nuril
    This document is a template for a preliminary discharge summary. It includes fields for patient information like name, chart number, and address. It also includes fields for admission and discharge details like date, attending physician, diagnoses, discharge disposition, predicted and actual length of stay. The template includes sections for documenting the patient's course in the hospital day-by-day, medications and activities on discharge, follow up appointments, and spaces for physician signatures.

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    Patient Name:

    TEMPLATE FOR MCP #


    Hospital Logo Preliminary Discharge Summary/Clinical Care Map Chart #:
    (It is imperative that all comorbidities and Addressograph
    interventions that affect Length of Stay (LOS)
    must be documented.)

    Admission Date: _____________________ Predicted LOS: _______________


    Attending Physician: _______________________________________________ To be completed by Medical Records:
    Admitting Diagnosis: ______________________________________________ Target LOS: ________ EDD: _________

    Discharge Date: __________________________________________________


    Discharge Disposition:  Home  Other facility  Deceased Against Medical Advice
    Most responsible Diagnosis: Did this affect LOS?
    Pre-Admission Comorbidity (Primary Diagnosis):  YES  NO
    Complications (Post Admission Comorbidity):  YES  NO
    Secondary Diagnosis:  YES  NO
    Clinical Care Map: Is the Patient Palliative?  Yes  No
    Did the patient receive blood components or blood products?  YES  NO
    Quantity (#units) transfused: RBC_______ Platelets ________ Plasma Products (Specify)______________________
    Blood Products: (Specify) _____________________________________For further information, contact family physician
    Course in hospital: (Includes investigations therapies, interventions and consults)
    Day 1: ________________________ Day 2 & 3: ____________________ Day 4 & 5: _______________________
    Day 6 & 7: ____________________ Day 8 & 9: ____________________ Day 10 or greater: _________________
    Medications on Discharge: (Name of drug, frequency and route)
    1.___________________________________________ 6._______________________________________
    2.___________________________________________ 7._______________________________________
    3.___________________________________________ 8._______________________________________
    4.___________________________________________ 9. _______________________________________
    5.___________________________________________ 10. ______________________________________
    Activities: Resume: Shower  Tub Bath Sponge Bath Housework  Drive Car Climb Stairs Sexual activity
    Incision – If you develop any signs of infection such as redness, swelling or drainage, please contact your doctor and call (insert
    phone # for Infection Control) leaving your name and telephone number for follow-up.
    Comments:

    Follow Up-Appointment: _____________________________ Date: ____________________


    (Diagnostic, Lab & Physician)
    _____________________________ Date: ____________________

    Physician’s Name: __________________________ _______________________ Date: ______________


    Print Signature
    For Medical Records Use: Discharge Summary Dictated:  Yes No Date: ___________________ Signed By: _____________
    Chart Assembled  Chart Abstracted  Chart Completed:  Coder’s Signature _________________

    ____________________________________________________________________________________________________________________________________
    WHITE COPY: Patient’s Chart YELLOW COPY: Family Doctor PINK COPY: Physicians’ Copy
    Form NL-DF01
    Effective Date:2011-09-07

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