DISCHARGE SUMMARY

Patient’s Name ( Last Name, First, Middle ) Age : Sex : Health Record No. :

Attending Physician : Date of Birth ( mm / dd / year ) : Room / Bed no. :

Admission Date ( mm / dd / year ) : ____________________ Time : _________________

Discharge Date ( mm / dd / year ) : ____________________ Time : _________________

Chief Complaints : _______________________________________________________________________________

Initial Diagnosis : ________________________________________________________________________________
Pertinent Physical Findings : _______________________________________________________________________
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Final Diagnosis : _________________________________________________________________________________
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Operation / Procedure : ___________________________________________________________________________
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Course in the Ward : ______________________________________________________________________________
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Treatment : _____________________________________________________________________________________
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Laboratory Findings :______________________________________________________________________________
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Condition of Patient upon Discharge : _______________________________________________________________

Follow-up Check-up : _____________________________________________________________________________
Take Home Medicines : ___________________________________________________________________________
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Signature over printed name of
Attending Physician
License No. : _________________

PDMC – MRD – DS – RV001