This will establish the chief complaint that is responsible for the patient’s visit to the hospital. When filling out the discharge summary, you will need to include the principal diagnosis. Thing to Include When Filling a Discharge Summary Form This area focuses on follow up outpatient visits on a daily schedule, diet, therapy recommendations, and other decision action steps should be taken to care for the patient correctly. This is where they list all the medications that are given to the patient. This part will list all the medical or surgical care given to the patient, medical alert, diagnosis, allergies, diet, immunization, infection, or patients functional status. This area will include the date of admission, signs, symptoms, hospital name, referral, date of discharge, and date of death. This part will include the physician’s full name and address of where the facility is located. This will include the patients first and last name, address, gender, date of birth, Social Security number, or other phone numbers. Usually, a discharge template will contain these information: Patient’s information
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