Medical Record #: [PatientID]

EMERGENCY ROOM DISCHARGE

SUMMARY
Patient Name: [PatientName]
Date of Birth: [DOB]
Attending Physician : [AttendingDr]
Date of Admission: [DateOfAdmission]
ER Arrival Date and Time [Arrivaldate] Discharge Date and Time [Discahrgedate]

Reason for Admission

[ReasonOfAdmission]

Co- morbid (s)

[CoMorbid]

[DiagnosisName]

[Diagnosis]

Significant Findings (Significant History & Physical Exam and Investigation Results)

[SignificantFindings]

[procedureandTreatmentName]

[procedureandTreatment]

Condition on Discharge

[ConditiononDischarge]

Follow-up appointment required

[followup]

Discharge Instructions

Instructions on medication [InsOnMed]
Instruction on Diet [InsOnDiet]
Home care instructions given [HomeCareIns]
Mode of Transportation [ModeOfTrans][others]

Other Instructions

[otherInstructions]

[DrSignature]

Name: Signature & Stamp of Doctor

Date: [Printdate]


In case of worsening of symptoms or any emergency condition, please call [phoneNumber] or visit [Hospital] Emergency Department.