Hospital Discharge Report

Hospital Discharge Report header data element

Hospital Discharge Report body data element

Hospital Discharge Report in its narrative form

Alerts

Encounter

Course of hospitalisation (Hospital stay)

Discharge details (structured information should be provided, however if not available, at least a summary note should be present).

Objective findings

Functional status can be assessed in several different ways, usually with a focus on the persona's abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one's own affairs. For details see: https://paciowg.github.io/functional-status-ig/

Discharge summary note

Care plan and other recommendations after discharge.

Care plan after discharge. Multiple care plans could be provided.

A description of the scope and nature of the plan.

Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.

Other recommendations (advice) after discharge. Multiple recommendations could be provided. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.

Hospital Discharge Report

Hospital Discharge Report header data element

Hospital Discharge Report body data element

Hospital Discharge Report in its narrative form

Alerts

Encounter

Course of hospitalisation (Hospital stay)

Discharge details (structured information should be provided, however if not available, at least a summary note should be present).

Objective findings

Functional status can be assessed in several different ways, usually with a focus on the persona's abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one's own affairs. For details see: https://paciowg.github.io/functional-status-ig/

Discharge summary note

Care plan and other recommendations after discharge.

Care plan after discharge. Multiple care plans could be provided.

A description of the scope and nature of the plan.

Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.

Other recommendations (advice) after discharge. Multiple recommendations could be provided. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.

Hospital Discharge Report

Hospital Discharge Report header data element

Hospital Discharge Report body data element

Hospital Discharge Report in its narrative form

Alerts

Encounter

Course of hospitalisation (Hospital stay)

Discharge details (structured information should be provided, however if not available, at least a summary note should be present).

Objective findings

Functional status can be assessed in several different ways, usually with a focus on the persona's abilities to perform basic activities of daily living (ADL), which include basic self-care such as bathing, feeding, and toileting and instrumental activities of daily living (IADL), which includes activities such as cooking, shopping, and managing one's own affairs. For details see: https://paciowg.github.io/functional-status-ig/

Discharge summary note

Care plan and other recommendations after discharge.

Care plan after discharge. Multiple care plans could be provided.

A description of the scope and nature of the plan.

Summary information on the medication recommended for the period after discharge, indicating whether the medication is changed or newly started. Compared to previous practices, the overview is supplemented with medication that has been discontinued.

Other recommendations (advice) after discharge. Multiple recommendations could be provided. E.g., recommendation to suggest hip replacement, reduce number of cigarettes, stop smoking, increase physical exercises, etc.