---
title: Discharge Summary
description: "## Overview - Write the summary you would want to read - succinct, highlight relevant details, clear accountability for follow up - Follow the [Discharge Checklist](https://vghneuro.ca/docs/cerner-discharge-checklist/)first - it will ensure that information is correct - Fix chart errors permanently: If…"
url: "https://vghneuro.ca/docs/discharge-summary/"
updated: "2023-09-18"
category: Clinical
tags:
  - CST
  - documentation
---

# Discharge Summary

## Overview

- Write the summary you would want to read - succinct, highlight relevant details, clear accountability for follow up
- Follow the [Discharge Checklist](https://vghneuro.ca/docs/cerner-discharge-checklist/)first - it will ensure that information is correct
- Fix chart errors permanently: If you need to fix something that pre-populated, fix it in the chart and refresh the document - don't leave the error in the chart
- If a section is blank, it will automatically delete. Manually delete sections with no-information text (e.g. "No Goals of Care Documented in CST Cerner")

## Admission date and time

Pre-populates

## Discharge date and time

If not known, write 'to be determined'

## Admitting diagnosis

Remove this section (leave blank)

## Most responsible diagnosis

- The diagnosis that cost the most to treat
- Will usually be the stroke, occasionally a complication following stroke (e.g. STEMI)
- Use common names with full spellings, and provide detail about localization, etiology, and treatment
  - Ischemic stroke, left MCA, secondary to atrial fibrillation, status post EVT
  - Intracerebral hemorrhage, left lentiform, secondary to hypertension

## Diagnoses for this visit & Chronic Problems

Pre-populates based on Discharge Diagnosis mPage component - make your changes there

### Tag as This Visit + Chronic

- Ischemic stroke / intracerebral hemorrhage
- Long term comorbidities e.g. atrial fibrillation, hypertension, diabetes
- Issues that require follow up (e.g. lung nodule) - use display as (e.g. Lung nodule, left lower lobe, for CT chest 2024 by GP)

### Tag as This Visit

- Complications that required more than trivial management (e.g. include a significant delirium, leave out UTI)

### Tag as Chronic

- Past medical history that wasn't relevant to hospital stay

## Advance care planning

Delete if "Advance Care Plan: No..."

## Goals of care

Delete if "No Goals of Care Documented in CST Cerner"

## Code status

Pre-populates if ordered. If not ordered document reason why or clarify prior to discharge / transfer

## Operative interventions

- List of invasive procedures done during the hospital stay
- Although prepopulated in template, data quality is poor and records are locked - this is one to fix in the discharge summary
- Includes surgeries, EVT procedures, stenting

## Procedure/Surgical History

Intended to be a lifetime list of procedures - unless you are entering this data, delete this section and anything it contains

## Other interventions

- Thrombolysis
- Mechanical ventilation

## Primary care provider

- Should pre-populate
- If pre-populated, that means that the primary care provider is correctly coded in Cerner, and will automatically get a report
- If the pre-populated name is incorrect or missing, send a Unit Clerk Communication Order to request an update
- **Adding a name here does not distribute the repor**t**, if the primary care provider isn't correctly pre-populated, they will not get a copy unless you correctly send a copy at signature**

## Names of relevant specialists

- **You are writing this so people know who is involved - **adding a name here does not distribute the report** - to send report you must correctly send a copy at signature**
- Suggest including
  - Admitting Stroke Neurologist
  - Follow up Stroke Neurologist
  - Discharging Stroke Neurologist
  - Any other specialist that was key / would benefit from being copied onto discharge / will follow up at discharge: Interventional radiology, rheumatology for vasculitis cases, endocrinologist that will follow as outpatient etc.

## Allergies

Pre-populates - correct any errors using the Allergies module

## Medications

- Pre-populates based on discharge medication reconciliation
- Planned transfers: write "Interim discharge summary, medication reconciliation to be done on day of discharge"

![](https://lh3.googleusercontent.com/10OJJ26JdFYx5b4ARanupvnEyzFY0zjOn6ExQKUepcF2qSCB-ZCdeRIZvw0Tzu8RO4Opvv7O4K6N6Bz69eThAd2vv74IfjI8aR13nyFmKMEz0vsNI8cN74WpIRIqnDkJMZlZGKLGrNZLDICydKoMMxo)

## Immunization administered

Pre-populates

## Lab results

Delete irrelevant pre-populated labs -and add in relevant labs using tags

![](https://i0.wp.com/vghneuro.ca/wp-content/uploads/2023/09/image.png?w=1100&ssl=1)

![](https://i0.wp.com/vghneuro.ca/wp-content/uploads/2023/09/image-1.png?w=1100&ssl=1)

## Functional history

Patient function prior to hospitalization, function at transfer / discharge (e.g. Patient lived alone and was independent prior to hospitalization. He currently is an overhead lift and requires assistance for all iADLs and ADLs)

## Hospital course

- Brief temporal course for each important diagnosis treated in hosptial
- Complex patient: 2-3 sentence overview of big picture events, then dive into issues

## Delivery measurements

Leave blank to delete

## Significant findings

- Results that allowed me to confirm the mechanism of stroke and monitoring of stroke
- Synthesize essence of report (e.g. Echo - no source of embolus; mild left atrial enlargement; not Normal LV, Normal RV, Normal PASP, etc. ; CT-CTA - acute left MCA ischemic stroke, M1 occlusion, good collaterals with penumbra; thyroid nodule for follow up)
- Include details of incidental findings that need follow up (e.g. specifics of a lung nodule)

## Procedures and treatment provided

Record information in Operative Interventions / Other Interventions, leave this blank to delete

## Discharge disposition

- Home
- Home with supports
- Home with outpatient rehabilitation
- Inpatient rehabilitation
- Long Term Care Facility 
- Repatriation to home hospital
- CAMU

Note: It is better to not mention particular names for PTN (Patient transfer network) or rehabilitation since these may change

### *Related*