Hospital Discharge
Hospital Course
Marty Infarction, a 73-year-old man, was admitted to the hospital on 3/1/12 with crushing chest pain
that was not relieved with sub-lingual nitroglycerine and had been ongoing for 4 hours. In the ED, he
was treated with aspirin, and beta blockers and an EKG demonstrated ST elevation. He was taken
immediately to the Cath lab for angioplasty and ultimately was found to have 80% stenosis of the RCA.
A stent was placed in the RCA. The Troponin and CK-MB lab series demonstrated elevation. Patient was
transferred to the telemetry floor the second day following admission, and discharged the third day
following an uneventful hospital course. [Insert narrative that indicates that labs, EKG and angiography
results mentioned are attached]

Histories: Patient has a personal history of hypertension, obesity, and Hyperlipidemia. Patient
admitted to the hospital as a current smoker with a pack/day habit for 35 years. Patient’s family
history is significant for mother deceased age 80 from a myocardial infarction; patient has a
personal 40 pack year smoking history. (Past medical, family and social histories)

Discharge Assessment and Plan: Diet: Low sodium, low cholesterol; activities: normal as
tolerated; smoking cessation counseling and medication prescribed.

Scheduled: Follow-up with PCP no more than 1 week post discharge. It is recommended that
the patient follows up with a cardiologist as an outpatient; this consultation has not been
scheduled and will be left to the PCP’s discretion.
All of the above information has been shared with the patient.
Core Data
Data Object
Demographic Data
Problem List
Active Medications
Allergies
Data Elements
Include all demographic information from the core (A) data from the CEDD
Acute Myocardial Infarction 410.9; Hypertension 401.1; Hyperlipidemia 272.2;
Obesity 279.00; Smoker V15.82
Toprol 50 mg; 1 po qd; Lipitor 10 mg, 1 po qd; Plavix 75 mg, 1 po qd; Lisinopril
20 mg, 1 po qd; Nitrostat 0.4 mg, 1 sublingual prn chest pain; Chantix 0.5 mg,
1 po qd
Sulfa Drugs