Hospitalist Discharge

HISTORY OF PRESENTING ILLNESS [describe presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PAST MEDICAL HISTORY [describe past medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MOST RESPONSIBLE DIAGNOSIS [list most responsible diagnosis for the admission] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) CONTRIBUTING OR SECONDARY DIAGNOSES [list other medical conditions that may have contributed to patient illness during the admission] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) COURSE IN HOSPITAL [describe course of patient's stay during the hospital, including special investigations, results, changes in vitals, and complications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MEDICATIONS AT DISCHARGE [list medications at time of discharge] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MEDICATION CHANGES DURING HOSPITAL STAY [list medications changed during the hospital stay and reasons for changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) DISCHARGE INSTRUCTIONS [describe discharge instructions and plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)