PEDIATRIC DISCHARGE SUMMARY - SUGGESTED FORMAT

PEDIATRIC DISCHARGE SUMMARY - SUGGESTED FORMAT

1. About you

Name, position & who you are dictating for

2. About the patient 

• Name

• Date of birth

• ULI

• Date of admission

• Date of discharge

3. Who should receive a copy of this summary

• Attending MD at discharge

• Other attending MDs from this hospitalization

• Primary MD (family doc, pediatrician or both)

• Any other physician who is going to see the child in follow-up

4. Clinical History

• Identifying statement

• Age, where admitted from, and what they were admitted for.  Can also include a statement of any past history that is DIRECTLY RELEVANT to reason for admission

• History of presenting illness:  Don’t need all details, but must include pertinent positives and negatives.  If presenting info in a timeline, use dates, or # days prior to admission.

• Past Medical History

• Prior hospitalizations and surgeries

• Perinatal history – as much detail as relevant – important for infants and kids with significant sequelae, not so important for an otherwise healthy 14 year old 

• Development (can be brief if normal, eg. “there are no developmental concerns”)

• Family History – as relevant to reason for admission

• Social History – as appropriate to reason for admission.  Be careful about mentioning details about family members that are not directly relevant to this patient’s condition.

• Allergies

• Immunizations

• Regular medications

5. Physical Examination on Admission

• Vitals

• Height, weight, head circumference (along with percentiles for age), +/- BMI if relevant

• Brief description of physical exam, with pertinent positives and negatives based on admitting problem

6. Treatment and Progress

• Brief description of what happened to the patient in hospital.  Do NOT give medication doses or read off lists of lab values or entire x-ray 

• Mention results of important investigations that aided in making the diagnosis or monitoring treatment

• For a straightforward case, can do as a single paragraph

• For a complex case, it is often easier to do a paragraph for each problem.  Start with saying something like “The following problems were addressed during the patient’s stay”

  • • The main reason for admission

    • The next most significant thing that was addressed

7. Investigations / Procedures

• Include only major or relevant ones

• Provide a brief summary of the result as it relates to reason for admission.  Do NOT read off the radiology report, or provide lists of lab values.

• If the patient is going to have follow-up testing done, include the most recent result of that test (eg. if they are going to have a follow-up ESR and CBC, include the actual results of the last test done prior to discharge).

8. Discharge Management Plan

• Where they were discharged to?

• Clinical status on discharge (Back at baseline?  Still residual signs or symptoms?

• Be specific enough that someone following this child could tell if there had been a significant change)

• Follow-up appointments – with dates (if available) or state how the appointment will be made (clinic will call parents, parents to call clinic, primary MD to arrange)

• Follow-up investigations – what, when, and who will receive and follow-up the results

• Discharge medications

• Drug name, dose, frequency, and duration

• Mention any changes made to home meds

9. Consultants

10. Complications

• Includes nosocomial infections, adverse events

11. Most Responsible Diagnosis

• Main reason for this admission 

12. Primary Diagnoses 

• Contributed to or complicated this admission

13. Other diagnoses 

• Present, but did not contribute to length of admission