Sample discharge summary format 2026

1. Click ‘Get Form’ to open the Sample discharge summary format in the editor.
2. Begin by entering the 'Name of attending' and 'Service' as 'Neonatology'.
3. Fill in the patient's name, medical record number, date of birth, sex, date of admission, and date of discharge.
4. In the 'History' section, provide the post-discharge name, reason for admission, birth weight, gestational age, and maternal history.
5. Document the physical examination details at discharge including weight, head circumference, and length with percentiles.
6. Summarize the hospital course by systems. Include pertinent lab results for respiratory, cardiovascular, fluids/nutrition, GI, hematology, infectious disease, neurology, psychosocial observations, and sensory evaluations.
7. Conclude with the condition at discharge including prognosis and discharge disposition.
8. Finally, enter details for care/recommendations including feeds at discharge, medications prescribed, medical equipment needs, car seat position screening if applicable, newborn screening status and immunizations received.

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