Surgical Procedures

History and Physical Examination and Laboratory Data: Describe the course of the disease up to the time the patient came to the hospital, and describe the physical exam and laboratory data on admission. Hospital Course: Describe the course of the patient's illness while in the hospital, including evaluation, treatment, outcome of treatment, and medications given. Discharged Condition: Describe improvement or deterioration in condition.

Disposition: Describe the situation to which the patient will be discharged (home, nursing home). Discharged Medications: List medications and instructions.

Discharged Instructions and Follow-up Care: Date of return for follow-up care at clinic; diet, exercise instructions.

Problem List: List all active and past problems. Copies: Send copies to attending physician, clinic, consultants and referring physician.

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