Dear Doctor,
Thank you for your ongoing care of Mr. John Smith, who presented on 1 November 2024 with sudden onset of severe abdominal pain, nausea, and vomiting, leading to his admission for further investigation of suspected appendicitis.
Upon initial investigations, their admission diagnosis was acute appendicitis.
They are being discharged today 1 November 2024 with a finalised/working diagnosis of:
1. Acute unruptured appendicitis
Relevant investigations have been included in this discharge summary for your records, and are also available on the Viewer/iEMR.
While an inpatient, the following medication changes occurred.
Commenced:
1. Metronidazole: 500mg, three times daily, orally, for 7 days.
2. Cefazolin: 1g, eight-hourly, intravenously, for 3 days.
Withheld:
1. Aspirin: 75mg, once daily, orally, Reason: Pre-operative bleeding risk, Duration: 3 days.
Ceased:
1. Paracetamol: 1g, four times daily, orally, Reason: Pain controlled with other analgesics.
Dose Changes:
1. Oxycodone: Previous dose 5mg, New dose 2.5mg, four-hourly, orally, Reason: Improved pain control post-operatively.
While an inpatient, Mr. John Smith has been referred to/for:
1. Surgical follow-up: For post-operative review in 2 weeks.
Upon discharge, Mr. John Smith requires follow up as below:
1. General Practitioner review: In 7-10 days for wound check and general recovery assessment.
2. Post-operative physiotherapy (outpatient): Referral pending for core strengthening exercises in 4 weeks.
We ask that you kindly:
1. Monitor wound healing and signs of infection.
2. Review pain management as required.
3. Discuss return to normal activities and exercise.
If you have any questions, please do not hesitate to contact the St. Elsewhere Hospital.
Kind Regards,
Dr. Emily White
St. Elsewhere Hospital
1234567
Clinician Specialty: Registrar
Dear Doctor,
Thank you for your ongoing care of [patient name], who presented on [date of presentation] with [presenting symptoms and reason for admission] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely. Write as a brief statement of full sentences.)
Upon initial investigations, their admission diagnosis was [working diagnosis or diagnoses at time of admission] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely. Write as a brief statement.).
They are being discharged today [date of discharge] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely.) with a finalised/working diagnosis of:
[final diagnoses at time of discharge] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely. Write as a numbered list.)
"Relevant investigations have been included in this discharge summary for your records, and are also available on the Viewer/iEMR."
"While an inpatient, the following medication changes occurred."
Commenced:
[medications commenced during admission] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely. Write as a numbered list. For each medication include: name, dose, schedule, route, and duration of treatment.)
Withheld:
[medications withheld during admission] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely. Write as a numbered list. For each medication include: name, dose, schedule, route, reason for withholding, and duration of withholding.)
Ceased:
[medications ceased during admission] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely. Write as a numbered list. For each medication include: name, dose, schedule, route, and reason for cessation.)
Dose Changes:
[medications with dose changes during admission] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely. Write as a numbered list. For each medication include: name, previous dose, new dose, schedule, route, and reason for change.)
While an inpatient, [patient name] has been referred to/for:
[referrals made during admission] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely. Write as a numbered list including the referral destination and reason for referral if provided.)
Upon discharge, [patient name] requires follow up as below:
[pending follow-up required after discharge] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely. Write as a numbered list including the type of follow-up and approximate timeline.)
We ask that you kindly:
[tasks for the GP to address following discharge] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely. Write as a numbered list.)
If you have any questions, please do not hesitate to contact the [hospital location](Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely.) Hospital.
Kind Regards,
[practitioner name](Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely.)
[treating hospital](Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely.)
[provider number](Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit entirely.)