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Internal Medicine Specialist Template

Hospital Discharge Summary

About this template

The Hospital Discharge Summary template is an essential tool for internal medicine specialists to document a patient's clinical course and provide follow-up care instructions upon discharge. This template helps clinicians summarize treatment methods, significant events, and changes in condition during the hospital stay. It also includes follow-up advice and education to ensure continuity of care. When used with Heidi, the AI medical scribe, this template streamlines the discharge process, ensuring comprehensive and accurate documentation. This template is ideal for internal medicine specialists and other healthcare providers involved in patient discharge planning.

Preview template

Patient Name: John Doe Age: 65 Gender: Male Admission Date: 2023-10-01 Discharge Date: 2023-10-10 Summary of Clinical Course: Mr. John Doe was admitted to the hospital on October 1, 2023, with acute exacerbation of chronic obstructive pulmonary disease (COPD). Upon admission, he was started on bronchodilators and corticosteroids. His condition improved with treatment, and he was weaned off supplemental oxygen by October 5, 2023. On October 7, 2023, he developed a mild fever and was diagnosed with a urinary tract infection, which was treated with antibiotics. His condition stabilized, and he was deemed fit for discharge on October 10, 2023. Follow-up Advice and Education: Mr. Doe is advised to continue using his prescribed inhalers and to follow up with his primary care physician in two weeks. He should monitor his symptoms and seek medical attention if he experiences increased shortness of breath or fever. Smoking cessation support was provided, and he is encouraged to attend pulmonary rehabilitation sessions. Discharge Medications: 1. Albuterol Inhaler - Use as needed for shortness of breath. 2. Prednisone 10 mg - Take once daily for 5 days. 3. Ciprofloxacin 500 mg - Take twice daily for 7 days. Discharge Diagnosis: 1. Acute exacerbation of COPD 2. Urinary tract infection Plan for Continuing Care: Mr. Doe will continue his COPD management plan and attend follow-up appointments as scheduled. He is encouraged to maintain a healthy lifestyle and adhere to his medication regimen.

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