Hospital Discharge Summary - Cannon

(I have uploaded previous notes from the patient's hospital stay in the context tab. Use that information to provide background information in this note.) (Throughout this note, use professional medical language suitable for an experienced clinician.) Hospital Course: "The patient is a" [age]"-year-old" [gender] "who presented with" [summary of initial symptoms]. "Our work-up revealed" [significant labs, imaging findings, medications administered, or consult details]. "Given these findings, the clinical picture was most consistent with a diagnosis of" [primary diagnosis], "though the differential diagnosis included" [differential diagnosis list]. (Insert brief discussion of each relevant differential and why they are not believed to be correct at this time in a narrative in-line format). "The patient was admitted with" [admitting diagnosis] "for" [primary treatment]. [Provide a summary of the patient's hospital course and how their medical condition changed throughout their hospitalization. Include details regarding specific medications, procedures, and interventions employed.] Physical Exam (Include both normal and abnormal findings explicitly mentioned in the transcript. Use proper, medical terminology. Only include headings for organ systems that are explicitly examined in the transcript. Leave out systems that are not mentioned. Do not include interpretations mentioned by the patient or physician, only objective signs and symptoms.) Constitutional: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Vital Signs: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] [Include specific values if mentioned.] Head: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Eyes: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Ears, Nose, Throat: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Neck: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Cardiovascular: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Respiratory: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Gastrointestinal: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Genitourinary: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Musculoskeletal: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (If specific joints, muscles, tendons, or ligaments are mentioned, create a specific bullet point for them and their exam findings. Be as specific as possible regarding these findings.) (Include the names of specific exam maneuvers and their results if mentioned by the physician.) Skin: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Neurologic: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Psychiatric: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Assessment & Plan: "The patient is a" [age]"-year-old" [gender] "who presented with" [summary of initial symptoms]. "Our work-up revealed" [significant labs, imaging findings, medications administered, or consult details]. "Given these findings, the clinical picture was most consistent with a diagnosis of" [primary diagnosis], "though the differential diagnosis included" [differential diagnosis list]. (Insert brief discussion of each relevant differential and why they are not believed to be correct at this time in a narrative in-line format). "The patient was admitted with" [admitting diagnosis] "for" [primary treatment]. "#" [Primary admitting condition/diagnosis] [include the ICD10 code for this diagnosis] "Assessment:" [Provide a succinct assessment of only this current condition and its response to treatment thus far. Provide any abnormal diagnostic findings related to this condition including labs and imaging with specific values and dates on which they were obtained.] "Plan:" "Medications:" [Provide a list of specific medications used to treat this condition including their specific dosages and duration.] (provide this information in bullet point list format) "Other Orders:" [Any additional orders, treatments, or monitoring requirements which are related to this specific condition.] (provide this information in bullet point list format) "Follow Up:" [Include and follow up with the patient's primary care physician or other medical specialists which will be needed and are pertinent to this diagnosis.] (Continue this format for all additional problems.)