| Data elements | Processes | ||
| Discharge summary | Patient instructions | Communication to follow-up clinician on day of discharge | |
| Presenting problem that precipitated hospitalization | x | x | x |
| Key findings and test results | x | x | |
| Final primary and secondary diagnoses | x | x | x |
| Brief hospital course | x | x | |
| Condition at discharge, including functional status and cognitive status if relevant | x - functional status o - cognitive status | ||
| Discharge destination (and rationale if not obvious) | x | x | |
| Discharge medications: | |||
| Written schedule | x | x | x |
| Include purpose and cautions (if appropriate) for each | o | x | o |
| Comparison with pre-admission medications (new, changes in dose/frequency, unchanged, meds should no longer take) | x | x | x |
| Follow-up appointments with name of provider, date, address, phone number, visit purpose, suggested management plan | x | x | x |
| All pending labs or tests, responsible person to whom results will be sent | x | x | |
| Recommendations of any sub-specialty consultants | x | o | |
| Documentation of patient education and understanding | x | ||
| Any anticipated problems and suggested interventions | x | x | x |
| 24/7 call-back number | x | x | |
| Identify referring and receiving providers | x | x | |
| Resuscitation status and any other pertinent end-of-life issues | o | ||
