GENERAL

This is useful when you are writing only the Hospital Course section of a form.

NEW DIAGNOSES
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MEDICATION CHANGES ON DISCHARGE
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TESTS NEEDING FOLLOWUP IN CLINIC 
(tests done while in hospital but results are still pending at time of discharge)
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TESTS and PROCEDURES TO BE DONE AFTER DISCHARGE
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FOLLOW-UP APPOINTMENTS AFTER DISCHARGE
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ACTIVE PROBLEMS ADDRESSED IN THE HOSPITAL
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Against Medical Advice



***********************
PATIENT IS REFUSING TO CONTINUE TREATMENT IN THE HOSPITAL AND IS LEAVING THE HOSPITAL AGAINST MEDICAL ADVICE
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The patient is leaving the hospital against medical advice.
I explained the risks of leaving against medical advice, including worsening infection, septic shock, and death.
The patient has capacity, voiced understanding of the risks of leaving against medical advice, and was able to explain these risks back to me.
I explained that we may prescribe oral antibiotics on discharge, but these oral antibiotics are NOT proven effective for the patient's type of infection, and the patient still has very high risks of sepsis and death despite these oral antibiotics.
Again, the patient voiced understanding of these risks, and was able to explain these risks back to me.



Death


BRIEF DEATH NOTE

Called to bedside by nursing for cessation of respirations.
Patient was in bed, and on examinatio there was no chest rise, ho heart or breath sounds to auscultation, no response to physical or verbal stimulus.
No palpable pulses. Eyes were fixed and dilated, with no corneal response.

The patient is DNR/DNI and no attempt at resuscuitation was made.
Time of Death was xxxx on xxxx

Family was contacted and notified, and they declined autopsy.




Patient Discharge Instructions


General

Make sure to go to all follow-up appointments. Your hospital plan of care includes these followup clinic appointments - they are necessary to ensure you continue to recover.

After you return home, make sure to take only the medications listed in your discharge summary. Some medications you took before the hospital may have been stopped or changed in dose. Also, you may be started on new medications. All of these changes will be described to you before you leave the hospital.

Follow a low fat and low salt diet

Go to the nearest ER immediately if you have any of the following:
New chest pain or shortness of breath
Bleeding or severe bruising 
Confusion 
Increased or severe pain 
Blue lips or fingernails 

Go to your primary doctor if you have any of the following:
Fever of 101 degrees or more 
Nausea or vomiting 
Constipation or diarrhea 
major weight loss or gain (more than 5 lbs in 1 week or more than 10 lbs in 1 month) 
More than normal mucous production, or yellow, green or smelly sputum


Low Potassium Diet

Low potassium diet - avoid oranges and orange juice, avoid tomatoes and tomato juice (including V8), avoid bananas, avoid all salt substitutes (such as Mrs Dash)


No NSAIDs

Avoid all Non-steroidal Anti-Inflammatories (NSAIDs) including Ibuprofen or Advil or Motrin or Nuprin, Naproxen or Alleve, Ketorolac or Toradol, Diclofenac or Voltaren


Seizure Precautions

No driving for 90 days after most recent seizure, no baths (shower only), no standing near open flames, no swimming alone, no climbing ladders, no operating heavy machinery.


COVID Patients


When you go home, continue to self-quarantine until XXXXXXXX
You will need to use your own bathroom and bedroom that are not shared with other people.

Make sure to go to all follow-up appointments. Your hospital plan of care includes these followup clinic appointments - they are necessary to ensure you continue to recover.

After you return home, make sure to take only the medications listed in your discharge summary. Some medications you took before the hospital may have been stopped or changed in dose. Also, you may be started on new medications. All of these changes will be described to you before you leave the hospital.

Call your Primary Care physician or go to the nearest Emergency Department if you have any of these:
- Fevers greater than 100.5
- Worsening cough or difficulty breathing
- Nausea, vomiting or diarrhea

Some online information:
Federal Resources: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html
Kentucky Resources:  https://govstatus.egov.com/kycovid19



Entire Document





Discharge Summary


MEDICINE DISCHARGE SUMMARY

DATE OF ADMISSION:
DATE OF DISCHARGE:
PRIMARY TEAM: 
STAFF PHYSICIAN:

CONSULTATIONS:

PROCEDURES:

IMAGING:

HISTORY OF PRESENT ILLNESS:


HOSPITAL COURSE:


#)
Continued to receive home medications xxxx and this was stable throughout the hospital stay.
Home medication xxxxx was initially held while xxxxx, but will be resumed on discharge.

ADMISSION PHYSICAL EXAM:

DISCHARGE PHYSICAL EXAM:

DISCHARGE MEDICATIONS:

START THESE NEW MEDICATIONS:

STOP THESE MEDICATIONS:

CHANGE THE DOSE OF THESE MEDICATIONS:


Continue all other previous home medications at their previous dose


DISCHARGE INSTRUCTIONS:
- Take all medications as prescribed
- Go to all scheduled followup appointments
- Follow a low fat and low salt diet

- Go to the nearest ER immediately if you have any of the following:
New chest pain or shortness of breath
Bleeding or severe bruising 
Confusion 
Increased or severe pain 
Blue lips or fingernails 

- Go to your primary doctor if you have any of the following:
Fever of 101 degrees or more 
Nausea or vomiting 
Constipation or diarrhea 
major weight loss or gain (more than 5 lbs in 1 week or more than 10 lbs in 1 month) 
More than normal mucous production, or yellow, green or smelly sputum

FOLLOWUP APPOINTMENTS:
- Primary Care Medicine within 1 week of hospital discharge

TESTS PENDING AT DISCHARGE: 
- None