Interior Health Authority: Discharge Summary Template

DATE OF ADMISSION: [Insert date of admission] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Use format DD/MM/YYYY for all dates) DATE OF DISCHARGE: [Insert date of discharge] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Use format DD/MM/YYYY for all dates) MOST RESPONSIBLE DIAGNOSIS [Describe the ONE diagnosis responsible for the longest portion of the Length of Stay (LOS) and that most impacted clinical care and treatment, written in capitals followed by a colon. Include onset date, relevant details, key details, dates of diagnosis, and associated complications.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Cause of Death may or may not be the Most Responsible Diagnosis. Keep this under 2-3 sentences. Never invent or create diagnosis information. Write in full sentences.) RELEVANT PRE-ADMIT DIAGNOSES/CONDITIONS [Summary of all diagnoses that existed before, or on admission, that impacted complexity, Length of stay, clinical care and treatment. For each condition include onset date, relevant details, key details, dates of diagnosis, relevant historical lab values, associated complications, and management strategies.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Never invent or create diagnosis information. Make a numbered list with each diagnosis on a new line. No spaces between list items.) PAST MEDICAL HISTORY [List any other pre-existing diagnoses or conditions pertinent for continuity of care post discharge that did NOT influence current admission and did not impact complexity, LOS, clinical care or treatment. Include past surgeries here that did not impact the hospital stay.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) OPERATIVE AND OTHER INTERVENTIONS IN HOSPITAL [List all operative and other interventions performed during hospitalization. Include any medical imaging done and briefly summarize results such as CTs, ultrasound, echocardiogram.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Format as a numbered list with no spaces between list items. Format as "Date:" followed by the intervention. When possible specify date and time of insertion and removal for mechanical ventilation and specify date of insertion for central lines, feeding tubes, TPN. Never invent procedures or imaging results.) COURSE IN HOSPITAL & CONDITION ON DISCHARGE [Provide narrative story of each significant, active medical problem during hospitalization, specialist consultants, findings and patient condition on discharge.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Significant means: affected treatment, extended LOS by 24 hours or more, or required treatment beyond maintenance for a pre-existing condition. When possible document administration of blood products, use of restraints, in addition to voluntary/involuntary status for psychiatric admissions. Provide date that sole focus of care changed to EOL/Palliative Care. Include doctors names if mentioned. Write in paragraph format with full sentences. Divide topics by paragraphs. Put a topic word or phrase at the beginning of each paragraph in CAPITALS such as DIABETES, or HEART FAILURE. Each paragraph should address a different medical problem or aspect of care. Never invent clinical course details or specialist consultant names.) "Additional discharge instructions are noted below." "Documentation generated with AI scribe. Content was reviewed by myself. Patient was not recorded in transcript. I am compliant with IHA AI Scribe policy." MEDICATIONS Changed: [List all changed medications including dosage, frequency, route, any changes or relevant comments for each and why changed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Make a numbered list for medications with each medication mentioned on a new line.) Continued: [List all continued medications including dosage, frequency, route, any changes or relevant comments for each] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Make a numbered list for medications with each medication mentioned on a new line.) Stopped: [List all stopped medications including dosage, frequency, route, any changes or relevant comments for each] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Make a numbered list for medications with each medication mentioned on a new line.) New Started: [List all started medications including dosage, frequency, route, any changes or relevant comments for each] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Make a numbered list for medications with each medication mentioned on a new line.) DISCHARGE LOCATION [Specify the location where the patient was discharged to. Include the specific name of the nursing home or other facility.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Options include: Home, home with referral for home support services, nursing home, transferred to another facility, unhoused.) DISCHARGE INSTRUCTIONS & ADVICE [Provide patient/family physician instructions including recommended follow-up appointments with physicians in specified number of days, outpatient lab or other tests required, specialist referrals made] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a point form list.) [Document if patient was transferred in from another facility and if patient already had a peripherally inserted central catheter, central line or ventilation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Particularly note if transferred from: Lillooet, Clearwater, Williams Lake, 100 Mile House. Indicate name of facility.) [Document MOST if status has changed during hospitalization] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely.) Allergies: [List applicable allergies as per Meditech] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely.) Cause of Death: [Indicate separately from Most Responsible Diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent cause of death information.) MAID: [List date MAID was performed, name of provider, medication used, diagnoses that were qualifications for MAID] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Other Forms Completed: [List forms completed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Forms may include: palliative forms, driving prohibition, work/school release, WorkSafe BC, MOST form, Mental Health Forms.) (Never come up with your own patient details, diagnoses, medications, procedures, interventions, assessment, plan, lab values, imaging results, specialist consultations, or discharge instructions - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)