scientific-writer 2.1.1__py3-none-any.whl → 2.2.2__py3-none-any.whl

scientific_writer/.claude/skills/clinical-reports/assets/discharge_summary_template.md

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+# Discharge Summary Template
+
+## Patient Information
+
+**Patient Name:** [Last, First]  
+**Medical Record Number:** [MRN]  
+**Date of Birth:** [MM/DD/YYYY]  
+**Age:** [years]  
+**Sex:** [M/F]
+
+**Admission Date:** [MM/DD/YYYY]  
+**Discharge Date:** [MM/DD/YYYY]  
+**Length of Stay:** [X days]
+
+**Admitting Service:** [Medicine/Surgery/Cardiology/etc.]  
+**Attending Physician:** [Name]  
+**Primary Care Physician:** [Name and contact]  
+**Consulting Services:** [List specialties that saw patient]
+
+---
+
+## Admission Diagnosis
+
+[Primary reason for hospitalization]
+
+Example: "Acute decompensated heart failure"
+
+---
+
+## Discharge Diagnoses
+
+[Numbered list, prioritized by clinical significance]
+
+**Primary Diagnosis:**
+1. [Primary diagnosis with ICD-10 code]
+
+**Secondary Diagnoses:**
+2. [Secondary diagnosis with ICD-10 code]
+3. [Additional diagnosis with ICD-10 code]
+4. [Comorbidity with ICD-10 code]
+
+Example:
+```
+1. Acute decompensated heart failure (I50.23)
+2. Acute kidney injury on chronic kidney disease stage 3 (N17.9, N18.3)
+3. Hypokalemia (E87.6)
+4. Type 2 diabetes mellitus (E11.9)
+5. Coronary artery disease (I25.10)
+```
+
+---
+
+## Hospital Course
+
+[Comprehensive yet concise narrative of hospital stay - can be organized chronologically or by problem]
+
+### Chronological Format:
+
+**[Date Range or Hospital Day 1-X]:**
+
+[Patient Name] was admitted to the [service] service with [chief complaint/presenting problem]. On presentation, patient was [clinical status]. Initial workup revealed [key findings].
+
+[Description of key events, interventions, and response to treatment organized by day or by problem]
+
+**Hospital Day 1:** [Events and interventions]
+
+**Hospital Day 2-3:** [Progression, response to treatment]
+
+**Hospital Day 4-7:** [Continued treatment, consultations, procedures]
+
+**Final Hospital Days:** [Stabilization, preparation for discharge]
+
+### Problem-Based Format (Alternative):
+
+**1. [Primary Problem]**
+- Presentation and initial management
+- Diagnostic workup
+- Treatment course
+- Response and outcome
+- Status at discharge
+
+**2. [Secondary Problem]**
+- [Similar structure]
+
+**3. [Additional Problems]**
+
+### Key Events and Interventions
+
+**Consultations Obtained:**
+- [Specialty] consulted on [date] for [reason]: [Recommendations]
+
+**Procedures Performed:**
+- [Procedure name] on [date]: [Indication, findings, complications if any]
+
+**Significant Diagnostic Studies:**
+- [Test/imaging] on [date]: [Key findings relevant to discharge care]
+
+**Complications:**
+- [Any complications that occurred]: [How managed]
+
+---
+
+## Procedures Performed During Hospitalization
+
+1. [Procedure name] ([Date])
+   - Indication: [Why performed]
+   - Findings: [Key findings]
+   - Complications: [None / specific complications]
+
+2. [Additional procedures]
+
+---
+
+## Hospital Course Summary (Brief Version)
+
+[One paragraph summary suitable for quick reference]
+
+Example:
+```
+Mr. [Name] was admitted with acute decompensated heart failure in the setting of 
+medication non-adherence. He was diuresed with IV furosemide with net negative 
+5 liters over 3 days, with significant improvement in dyspnea and resolution of 
+lower extremity edema. Echocardiogram showed EF 30%, similar to prior. Kidney 
+function improved to baseline with diuresis. He was transitioned to oral diuretics 
+on hospital day 3 and remained stable. Patient was ambulating without dyspnea on 
+room air by discharge. Comprehensive heart failure education was provided.
+```
+
+---
+
+## Discharge Physical Examination
+
+**Vital Signs:**
+- Temperature: \_\_\_\_\_ °F
+- Blood Pressure: \_\_\_\_\_/\_\_\_\_\_ mmHg
+- Heart Rate: \_\_\_\_\_ bpm
+- Respiratory Rate: \_\_\_\_\_ breaths/min
+- Oxygen Saturation: \_\_\_\_\_% on [room air / O2]
+- Weight: \_\_\_\_\_ kg (Admission weight: \_\_\_\_\_ kg)
+
+**General:** [Appearance, distress level]
+
+**Cardiovascular:** [Heart sounds, edema]
+
+**Pulmonary:** [Breath sounds, work of breathing]
+
+**Abdomen:** [Tenderness, bowel sounds, distention]
+
+**Extremities:** [Edema, pulses]
+
+**Neurological:** [Mental status, focal deficits]
+
+**Wounds/Incisions (if applicable):** [Healing status]
+
+---
+
+## Pertinent Laboratory and Imaging Results
+
+### Discharge Labs ([Date])
+
+| Test | Result | Reference Range |
+|------|--------|----------------|
+| WBC | [Value] | [Range] |
+| Hemoglobin | [Value] | [Range] |
+| Platelets | [Value] | [Range] |
+| Sodium | [Value] | [Range] |
+| Potassium | [Value] | [Range] |
+| Creatinine | [Value] | [Range] |
+| [Other relevant labs] | [Value] | [Range] |
+
+### Imaging/Diagnostic Studies
+
+**[Study name] ([Date]):** [Key findings relevant to outpatient management]
+
+---
+
+## Discharge Medications
+
+[Complete list with clear indication of changes from admission]
+
+### New Medications (Started During Hospitalization)
+
+1. **[Medication name]** [dose] [route] [frequency]
+   - Indication: [Why prescribed]
+   - Duration: [If limited duration]
+   - Special instructions: [With food, time of day, etc.]
+
+### Changed Medications (Dose or Frequency Modified)
+
+2. **[Medication name]** [NEW dose] [route] [frequency]
+   - **CHANGED FROM:** [Previous dose and frequency]
+   - Reason for change: [Why modified]
+
+### Continued Medications (No change from home medications)
+
+3. **[Medication name]** [dose] [route] [frequency]
+   - **CONTINUED** from home regimen
+
+### Discontinued Medications (Stopped During Hospitalization)
+
+4. **[Medication name]** - **DISCONTINUED**
+   - Reason: [Why stopped]
+
+### Complete Medication List for Patient
+
+[Consolidated list in simple format for patient]
+
+```
+1. Furosemide 40 mg by mouth once daily [NEW - for fluid management]
+2. Carvedilol 12.5 mg by mouth twice daily [CONTINUED]
+3. Lisinopril 20 mg by mouth once daily [CONTINUED]
+4. Metformin 1000 mg by mouth twice daily [CONTINUED]
+5. Aspirin 81 mg by mouth once daily [CONTINUED]
+```
+
+---
+
+## Discharge Condition
+
+**Overall Status:** [Stable / Improved / Baseline / Requires continued care]
+
+**Specific Assessments:**
+- Hemodynamic status: [Stable]
+- Respiratory status: [Room air / Oxygen requirement]
+- Mental status: [Alert and oriented x3 / Other]
+- Functional status: [Ambulatory / Requires assistance / Bedbound]
+- Pain control: [Adequate / Inadequate]
+- Wound healing (if applicable): [Appropriate / Delayed]
+
+Example:
+```
+Patient is hemodynamically stable, ambulatory without assistance, no supplemental 
+oxygen requirement, euvolemic on physical exam, pain well-controlled, and has 
+returned to baseline functional status.
+```
+
+---
+
+## Discharge Disposition
+
+[Where patient is going after hospital discharge]
+
+Options:
+- Home with self-care
+- Home with home health services
+- Skilled nursing facility
+- Acute rehabilitation facility
+- Long-term acute care hospital
+- Hospice (home or facility)
+- Left against medical advice (AMA)
+- Transferred to another acute care facility
+
+**Discharge Disposition:** [Selection from above]
+
+**Services Arranged:**
+- [ ] Home health nursing
+- [ ] Physical therapy
+- [ ] Occupational therapy
+- [ ] Durable medical equipment: [List items]
+- [ ] Home oxygen: [Flow rate and delivery method]
+- [ ] Other: [Specify]
+
+---
+
+## Follow-Up Appointments
+
+1. **[Specialty/PCP]** with Dr. [Name]
+   - Date/Time: [Scheduled date and time] OR [Within X days/weeks]
+   - Location: [Clinic name and address]
+   - Phone: [Contact number]
+   - Purpose: [What needs to be addressed]
+
+2. **[Additional appointments]**
+
+### Pending Studies/Labs at Discharge
+
+- [Test name]: [When due, where to go, reason]
+- Results will be sent to: [Provider name]
+
+### Referrals Placed
+
+- [Specialty]: [Reason for referral, contact information]
+
+---
+
+## Patient Instructions
+
+### Activity
+
+- [Specific activity restrictions or recommendations]
+- Example: "Resume normal activities as tolerated. Avoid heavy lifting >10 lbs for 2 weeks."
+
+### Diet
+
+- [Dietary restrictions or recommendations]
+- Example: "Low sodium diet (less than 2 grams per day). Fluid restriction to 2 liters per day."
+
+### Wound Care (if applicable)
+
+- [Incision care instructions]
+- [Dressing change frequency]
+- [When stitches/staples should be removed]
+
+### Self-Monitoring
+
+- [What patient should monitor at home]
+- Example: "Weigh yourself every morning. Call doctor if weight gain >2 lbs in 1 day or >5 lbs in 1 week."
+
+### Equipment/Supplies
+
+- [Equipment provided or prescribed]
+- [How to use]
+
+### Medications
+
+- [General medication instructions]
+- [Importance of compliance]
+- [What to do if dose missed]
+
+---
+
+## Return Precautions / Warning Signs
+
+**Call your doctor or return to emergency department if you experience:**
+
+- [Specific warning signs relevant to condition]
+- [When to seek immediate care vs. call doctor]
+
+Example for heart failure:
+```
+- Worsening shortness of breath or difficulty breathing
+- Chest pain or pressure
+- Severe swelling in legs or abdomen
+- Weight gain more than 2 lbs in one day or 5 lbs in one week
+- Dizziness, lightheadedness, or fainting
+- Fever >101°F
+- Any other concerning symptoms
+```
+
+**Emergency Contact Numbers:**
+- Primary care physician: [Phone]
+- Specialty clinic: [Phone]
+- After-hours nurse line: [Phone]
+- 911 for emergencies
+
+---
+
+## Patient Education Provided
+
+Topics discussed with patient and/or family:
+- [ ] Disease process and prognosis
+- [ ] Medication purpose, dosing, and side effects
+- [ ] Warning signs and when to seek care
+- [ ] Activity and dietary restrictions
+- [ ] Follow-up appointments
+- [ ] Use of medical equipment
+- [ ] [Other specific topics]
+
+**Patient/Family Understanding:**
+[Patient and family verbalize understanding of discharge instructions / Teach-back method used and patient able to repeat key points / Interpreter used]
+
+**Written Materials Provided:**
+- [ ] Discharge instructions
+- [ ] Medication list
+- [ ] Disease-specific education materials
+- [ ] Emergency contact information
+- [ ] Appointment information
+
+---
+
+## Code Status at Discharge
+
+**Code Status:** [Full code / DNR / DNI / Other limitations]
+
+[If changed during hospitalization, note when and why]
+
+---
+
+## Additional Information
+
+### Advance Directives
+
+- [ ] Advance directive on file
+- [ ] Healthcare proxy designated: [Name and contact]
+- [ ] Living will present
+
+### Social Situation
+
+[Relevant social factors affecting discharge plan]
+- Living situation: [Lives alone / with family / assisted living]
+- Caregiver support: [Available / Limited / None]
+- Transportation: [Adequate / Needs assistance]
+- Barriers to compliance: [Financial / Cognitive / Language / Other]
+
+### Pending Issues at Discharge
+
+[Tests or consultations still pending that require outpatient follow-up]
+
+---
+
+## Signature
+
+**Prepared by:**  
+[Physician name, credentials]  
+[Pager/Contact number]
+
+**Cosigned by (if resident/fellow):**  
+[Attending physician name]
+
+**Date and Time:** [MM/DD/YYYY at HH:MM]
+
+**Electronically signed:** [Yes/No]
+
+---
+
+## Template Completion Checklist
+
+- [ ] All discharge diagnoses listed with ICD-10 codes
+- [ ] Hospital course summarized clearly
+- [ ] All procedures documented
+- [ ] Discharge medications reconciled and clearly marked (new/changed/continued/stopped)
+- [ ] Follow-up appointments scheduled or timeframe provided
+- [ ] Patient education documented
+- [ ] Return precautions specific to patient's conditions
+- [ ] Pending tests/results documented with follow-up plan
+- [ ] Code status documented
+- [ ] Completed within 24-48 hours of discharge (institutional requirement)
+- [ ] Sent to primary care physician and relevant specialists
+- [ ] Copy provided to patient
+
+---
+
+## Notes
+
+**Timing Requirements:**
+- CMS requires completion within 30 days
+- Many hospitals require 24-48 hours
+- Should be available for follow-up appointments
+
+**Distribution:**
+- Send to primary care physician
+- Send to referring physician
+- Send to consulting specialists involved in care
+- Provide copy to patient
+- Upload to shared HIE (Health Information Exchange)
+
+**Quality Measures:**
+- Medication reconciliation required
+- Clear communication of changes
+- Specific follow-up plans
+- Patient education documented
+
+