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    siva
    The document outlines the national standard for patient discharge summaries, listing information that should be included. It mandates inclusion of patient identifying information like name, address, date of birth, gender, and health identifier. Clinical information such as date and reason for admission, source of referral, diagnosis, procedures, investigations, discharge condition, and instructions must also be documented. The attending physician must sign the summary with their details. Additional information may be required for maternity cases or those involving trauma.

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    Summary

    Uploaded by

    siva
    429 views1 page
    The document outlines the national standard for patient discharge summaries, listing information that should be included. It mandates inclusion of patient identifying information like name, address, date of birth, gender, and health identifier. Clinical information such as date and reason for admission, source of referral, diagnosis, procedures, investigations, discharge condition, and instructions must also be documented. The attending physician must sign the summary with their details. Additional information may be required for maternity cases or those involving trauma.

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    The document outlines the national standard for patient discharge summaries, listing information that should be included. It mandates inclusion of patient identifying information like name, address, date of birth, gender, and health identifier. Clinical information such as date and reason for admission, source of referral, diagnosis, procedures, investigations, discharge condition, and instructions must also be documented. The attending physician must sign the summary with their details. Additional information may be required for maternity cases or those involving trauma.

    Copyright:

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

    Summary

    Uploaded by

    siva
    The document outlines the national standard for patient discharge summaries, listing information that should be included. It mandates inclusion of patient identifying information like name, address, date of birth, gender, and health identifier. Clinical information such as date and reason for admission, source of referral, diagnosis, procedures, investigations, discharge condition, and instructions must also be documented. The attending physician must sign the summary with their details. Additional information may be required for maternity cases or those involving trauma.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 1

    National Standard for Patient Discharge Summary Information

    Name Optionality Definition


    Patient complete name Mandatory
    Address and contact details Mandatory The location to be used to contact or correspond with the
    of the patient patient. This would normally be the patient’s usual home
    address.
    Date of birth / age Mandatory dd/mm/yyyy format.
    Gender Mandatory
    Health identifier / IP number Mandatory IPD number or OPD number assigned to each member by
    hospital
    Consultant details Mandatory Treating doctor name, specialisation and registration number
    Unit optional Department
    Date of admission / time Mandatory dd/mm/yyyy format.
    Date of discharge / time Mandatory dd/mm/yyyy format.
    Source of referral Mandatory Examples would include GP/self- referral/ambulance
    service/out-of-hours service/other hospital/other (please
    specify)
    Method of admission Mandatory Example would include elective/emergency/transfer.
    Room / ward Mandatory Patient occupied room type/ number etc
    Diagnosis Mandatory The principal and additional diagnoses relevant to this inpatient
    stay should be recorded
    Reason for hospitalization Mandatory chief complaint and/or history of present illness
    Past and family history of Mandatory Previous ailments and treatment details
    the patient
    Examination findings Mandatory Vital signs recorded during admission period
    Procedures and treatment Mandatory a description of surgical, medical treatment and events
    provided occurring to a patient during his/her hospital stay)
    Investigation findings Mandatory Investigation details in support to diagnosis / treatment
    Patient’s discharge condition Mandatory Any documentation that gives a sense for how the patient is
    doing at discharge or the patient's health status on discharge
    Patient/family Instructions Mandatory Discharge medications / acidity orders/ therapy orders and
    follow up instruction
    Attending physician’s Mandatory physical signature of the attending physician on the discharge
    signature summary with designation and registration number of the
    doctor
    GPLA - In case of maternity Mandatory about the patients' obstetric history ex. G1 P1 L0 A0
    MLC / FIR and details of Mandatory Copy of injury report is commonly issued by the medical officers
    accident in case of RTA/
    trauma

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