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Discharge Summary Template Date of Admission
Brief Hospital Course: This should be a brief, problem-based summary of the admission. Include all pertinent lab values and radiology studies here. If the
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FORM FDA 3500A SUPPLEMENT
should be left blank. file a separate form FDA 3500A for each patient as long visit notes or the hospital discharge summary.
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SIGN 128 The SIGN discharge document
discharge from the hospital identified in item 1. If item 8a is completed, 8b must be blank. 8b. Date of death. Date. If the patient died
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