An effective outpatient discharge summary should include information like patient demographics (name, age, gender), admission and discharge dates, diagnosis and reason for hospitalization, treatment provided during the hospital stay, test results and their interpretation, medication reconciliation, including changes and discharge medication list, care plan, including follow-up care instructions and appointments, and contact information for the primary care provider and other involved healthcare providers.
To create an accurate and comprehensive summary, make sure to use a standardized template like the one provided by Fill to ensure consistency and completeness. Review the patient’s medical record and collaborate with the hospital care team, including physicians, nurses, and case managers.