01-FM-MSO-004-00 Discharge Summary

Discharge Summary Date: Time:
HN: Room:
Name:
Date of Birth Gender:
Age:
Physician:
Allergies: MD Code

Admission date ………….…..…. Time …………..…. Discharge date ……………....…Time …………..…. LOS ……..…..days AN. ……………………...............
Reason for Admission:
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Discharge Diagnosis

A. Principal Diagnosis : .........................................................…...…………………………………..……………….……………………………

B. Comorbidities : ..............……………………………………………………………………………………………………
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C. Complications : ......…………………………………………………………………………………………………………

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D. Other diagnosis :.....…………………………………………………………………………………………………………
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E. External Cause of Injury : …………………………………………………………………………………………………
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Procedure / Operation (s)
1. …………………………………………………………………………………………………………………………………
2. …………………………………………………………………………………………………………………………………

3. …………………………………………………………………………………………………………………………………
4. …………………………………………………………………………………………………………………………………

Significant Clinical and Investigational Findings :
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Hospital Course, Medication (s) and Treatment :

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Patient's condition upon discharge Type of discharge
By transfer
Recovered Dead (no autopsy) With approval Other (specify).............................
Improved Dead (autopsy) Against advice D ea th
Not improved By escape

Attending Physician’s Signature……………………………………MD Code.................Date ………………… Time …….…

FM-MSO-004-00