Admission Template

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KIMBERLEY HOSPITAL – INTERNAL MEDICINE DISCHARGE SUMMARY TEMPLATE Admission Doctor: Admission Date: Discharge Date: PRESENTING COMPLAINT: SYSTEMIC HISTORY: - CVS: - RESP: - CVS: - GIT: - GENITO-URINARY: - ENDOCRINE: - MUSCULOSKELETAL: - ENT: PREVIOUS MEDICAL HISTORY: - ILLNESSES: - SURGERY: - CHRONIC MEDICATION: SOCIAL HISTORY: - SMOKER - ALCOHOL - RECREATIONAL DRUGS ON EXAMINATION: - VITALS: - GENERAL EXAMINATION: - SYSTEMIC EXAMINATION: o CVS: o RESP: o CVS: o GIT: o GENITO-URINARY: o ENDOCRINE: o MUSCULOSKELETAL: o ENT:

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Transcript of Admission Template

KIMBERLEY HOSPITAL INTERNAL MEDICINEDISCHARGE SUMMARY TEMPLATE

Admission Doctor:Admission Date:Discharge Date:

PRESENTING COMPLAINT:

SYSTEMIC HISTORY: CVS: RESP: CVS: GIT: GENITO-URINARY: ENDOCRINE: MUSCULOSKELETAL: ENT:

PREVIOUS MEDICAL HISTORY: ILLNESSES: SURGERY: CHRONIC MEDICATION:

SOCIAL HISTORY: SMOKER ALCOHOL RECREATIONAL DRUGS

ON EXAMINATION: VITALS: GENERAL EXAMINATION: SYSTEMIC EXAMINATION: CVS: RESP: CVS: GIT: GENITO-URINARY: ENDOCRINE: MUSCULOSKELETAL: ENT:

SPECIAL INVESTIGATIONS: BLOODS: ECHOCARDIOGRAM: LUNG FUNCTION: ULTRASOUND: CT/MRI: OTHER:

ASSESSMENT:

ADMISSION PLAN:

PROGRESS DURING ADMISSION:

DISCHARGE PLAN: MEDICATION: FOLLOW UP:

DISCHARGE SUMMARY COMPLETED BY:


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