Adaptive Geriatrics Discharge Summary
Insert facility address here
(o) (804)xxx-xxxx (best number for families/providers to contact you) (f) (804)xxx-xxxx (best place to fax orders/notes)
Patient Name:
DOB:
Date:
Admitting Diagnoses:
Rehab course: Admission date: ___/___/___ Projected D/C date: ___/___/___
PMSH:
Medical:
hospitalization
Allergies:
Important medication changes:
*see med list for complete list of meds*
Page 1 of 4
New Diagnoses since
ROS: circle if positive, strike if negative
KEY FINDINGS:
Constitutional: Wt Loss, Wt Gain, Dizziness, Lightheadness, Fever, Chills,
Lethargy
Skin: Rash, Pruritus, Blister, Ulcer
Eyes: Poor/Blurred Vision, Diplopia, Blindness, Glaucoma
ENT: Hearing prob, Tinnitus, Runny nose, Sore throat, Difficulty chewing
Resp: SOB, DOE, PND, Orthopnea, Wheezing, Cough, Tachypnea
Sputum production
CV: Chest pain, Tightness, Palpitations, Edema
Breasts: Lumps/Masses, Nipple discharge
GI: Loss of appetite, Pain, Dysphagia, Nausea, Vomiting, Diarrhea,
Constipation, Melena, Hematemesis
GU: Dysuria, Hematuria, Polyuria, Hesitancy, Frequency, Discharge,
Vaginal bleeding, Pruritus
Immuno/Allergies: Seasonal allergies, Joint pain, Swelling, Arthritis
Endo: Polydipsia, Polyphagia, Heat/Cold intolerance
Musculoskeletal: Joint pain, Swelling, Stiffness, Weakness, Parathesias,
Speech
Neuro: HA, Confusion, Seizures, Syncope, Numbness, Weakness,
Paresthesias, Dysphasia, Memory loss
Psych: Anxiety, Depression, Insomnia, Suicidal/Homicidal ideation
PHYSICAL EXAM: (Check if normal, if abnormal write results)
GEN: NAD Obese
WD/WN
CONST: T _______ BP _______ P _______ R ______
EYES:
PERRLA
Lids/Conjunctiva Nml
Sclera Anicteric
Nml Fundi
ENT:
NCAT
Nml TMs/EACs
Nml Nasal Mucosa/Turbinates
Nml Oropharynx/Oral mucosa
Nml Dentition/Gum
NECK:
Neck symmetrical and trachea midline
Thyroid normal size with no masses
RESP:
Nml Effort
Clear Bilat
No tactile fremitus or crepitus palpated
No Hyperessonance or dullness
CV:
No JVD
No Bruits
Regular Rate
No Rubs
ABD:
Nondisplaced PMI
Regular Rhythm
Flat
Nontender
Nondistended
No Masses
Nml Rectal Tone
GU: Male:
Nml Testes
Female:
LYMPH:
MK:
Soft
No Hernia
No Hemorrhoids
No Discharge
No Vaginal discharge
No Nipple discharge
No Adenopathy in two or more regions
Nml gait and station
No Deformity
No Contractures
No clubbing or cyanosis of nails
Nml muscle tone
Page 2 of 4
Obese
No Skin changes
No Spinal tenderness
SKIN:
Nml DP/PT Pulses
No Penile Lesions
No Masses
No Gallops
No Hepatosplenomegaly
Nml External Genitalia
BREASTS:
Nml S1 S2
No Peripheral Edema
Nml Bowel Sounds
No Murmurs
No Rash
Nml ROM
No Ulcers
No Active synovitis
No Subluxation
Nml strength
No nodules or induration
Poor Historian due to:
All other ROS negative
KEY FINDINGS:
Neuro:
Alert
Nml DTR’s
Psych:
Oriented
CN 2-12 Intact
Absent tremor
Nml Light Touch
No Abnormal movements
Nml Mood/Affect
Mental Status:
Unchanged from baseline
See attached BIMS
Functional Status:
Indicate level as follows: 1= Independent:; 2= uses adaptive device; 3= help from others; 4= totally
dependent:
Ambulation: ___
Toileting: ___
Nutrition:
Weight: _____
stable
Diet:
No restrictions
Eating: ___
Transfers: ___
Ability to position in bed:_ __
increase
decrease of ____ pounds over ___ months
Special diet/consistency: __________________________________
PERTINENT LAB DATA/TEST RESULTS:
Follow up:
Please make a follow up appointment with your primary care doctor within 2 weeks of discharge
You should have the following blood work done:
Please have your doctor check: ________________________________________ in __________
days/weeks
________________________________________ in __________
days/weeks
You should have the following tests done:
Please have your doctor schedule a ___________________________ in ______ days/weeks
You should see the following specialists within 2 weeks of discharge:
______________________________
Discharge Diagnoses/Follow up plans:
> 30 minutes spent in discharge summary
Signature: __________________ Signature: __________________ Signature: ___________________
Your Name, Credentials
Provider you work with
Provider you work with
Page 3 of 4
Discharge Medication List/Prescription
Your Name
DEA #: xx123456 NPI#: 1234567
Facility Address
(o) (804)XXX-XXXX (best number for pharmacist to call) (f) (804)xxx-xxxx (best place to fax orders)
Patient Name: _________________________________________
Call
these
meds
in
Medication and
dose
Instructions for administration
Date: _____________
Dispense
#
Refills
Brand Medically Necessary
Voluntary Formulary Permitted: _______________________________________
Your Name, Credentials
*IN ORDER TO BE VALID, THIS FORM MUST BE CALLED IN TO THE PHARMACY FROM THE NURSING FACILITY*
Page 4 of 4