Patient Information
Full name
Date of birth
Dates of admission and discharge
Diagnosis and Hospital Course
Reason for hospitalization
Significant findings from diagnostic tests
Final diagnosis upon discharge
Brief summary of care, procedures, and treatment provided (Evolution)
Discharge Condition and Instructions
Condition of patient at discharge (stable, improved, etc.)
Follow-up needs (e.g. appointments, labs, exams)
Medications prescribed, including names, doses, frequencies
Post-discharge instructions for self-care and restrictions
Pending Test Results
Any test results still pending at discharge
Plan for patient notification of results
Providers
Names and contact information for all physicians who cared for the patient
Name and contact information for the discharging physician
Brief overview of the hospital course and highlights from the discharge plan