Sample Discharge Summary
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DISCHARGE SUMMARY TEMPLATE Approved by the Provincial HIM Leadership Committee March 19, 2010 DEMOGRAPHIC AND ADMINISTRATIVE DATA PATIENT NAME ADDRESS CHART NUMBER ACCOUNT NUMBER (Meditech Registration Account Number) HEALTH CARE NUMBER DOB GENDER ADMISSION DATE DISCHARGE DATE REFERRING PHYSICIAN MOST RESPONSIBLE PROVIDER (Attending physician) FAMILY PHYSICIAN ADMISSION DIAGNOSISWorking diagnosis at time of admission ( Do not use abbreviations.) MOST RESPONSIBLE DIAGNOSIS (MRDx) The one diagnosis or condition that can be described as being most responsible for the patient’s stay in hospital (Do not use abbreviations.) PRE-ADMIT COMORBIDITY(IES) A condition(s) that coexists at the time of admission (Do not use abbreviations.) POST- ADMIT COMORBIDITY(IES) A condition(s) that arises post-admission (Do not use abbreviations..
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