Patient discharge form sometimes referred to as patient discharge summary is a document issued by a hospital to an admitted patient at the time of his discharge from the hospital.
Who can issue patient discharge form?
On duty doctor or consultant can only decide whether the patient is ready to go home. None other than the doctor can issue the form.
Who fills the discharge form?
A doctor who decided the discharge of the patient and who treated the patient during a hospital stay is only authorized to fill the form and precedes it to the billing department through nursing staff.
Components of a patient discharge form
A patient discharge form has to include all the basic information of the patient and detailed information of his condition along with instructions for home. We will discuss them here one by one.
- Patient information: Patient name, age, gender, date of birth along with their medical record number if issued by the hospital must be filled very carefully. This is a very serious matter and we do not want to mix the patients with the same names. Patient’s contact number and email address if any is also very important to mention.
- Reason for Admission: Presenting complaints of the patients for which he was admitted in the hospital are a must to write and all the details about his complains are to be mentioned in the discharge form. That is why history taking of the patient is always emphasized.
- Diagnosis at the time of admission: A necessary thing to fill in the form is the diagnosis. On the basis of presenting complaints, a doctor diagnoses the patient, and this is the only justification for admission in hospital.
- Treatment Provided at the hospital: In the patient discharge form, the doctor has to write how he was treated on the basis of his history, examination, and diagnosis. He has to mention all the drugs whether oral or Intravenous or through any other route of administration with details. If any investigations were done, they are mentioned with their final reports. If a patient is treated by any surgery, the procedure and per-operative findings are to be written in the column of treatment at the hospital.
- Condition on Discharge: Being in a medical profession, we have to take every step carefully and document it even more carefully. The condition on discharge is a huge responsibility for the hospital and must be assessed and filled accordingly.
- Important Dates: Important dates like date and time of admission, date of discharge, duration of stay at the hospital are important to write.
- Medication on discharge: Patient even if discharged from the hospital is sometimes prescribed with oral medicine to take at home. This occurs almost always in case of surgical patients. So, it is the prime duty of the doctor to fill this portion of the discharge summary with the proper name of the drug, proper dosage, frequency and for how long he or she has to take this medicine.
- Instructions on Discharge: In the end, the patient is given some instructions on diet, activity, wound care and follow up a plan that when does he have to return for a checkup.