Hospitalist Discharge
Created by
Grace Wong
Specialty
Family Medicine Specialist
Last edited
10/20/2026
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0 times
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About this template
A structured template for documenting a patient's hospital admission and discharge, including the presenting illness, relevant medical history, diagnoses, hospital course, medications, and discharge plan. It supports concise communication and continuity of care after hospitalization.
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History of Presenting Illness
72-year-old male (PHN: 9842-716-309) admitted on 12/05/2026 at 14:30 with a 3-day history of progressive SOB, orthopnea, and bilateral pedal edema. Associated with dietary sodium indiscretion. Denies chest pain, palpitations, or fever.
Past Medical History
- HFrEF (EF 35 % in 2024)
- HTN
- T2DM
- Atrial fibrillation (on apixaban)
Most Responsible Diagnosis
Acute decompensated heart failure
Contributing or Secondary Diagnoses
- Pre-renal acute kidney injury (resolved)
- Chronic atrial fibrillation
Course in Hospital
Presented to ED with SpO2 88 % on room air, BP 158/92 mmHg, HR 94 bpm, T 36.8 °C. CXR showed cardiomegaly and pulmonary vascular congestion. ECG showed rate-controlled AF without acute ischemic changes. Labs notable for NT-proBNP 4,500 ng/L, Cr 145 µmol/L (baseline 95 µmol/L), K 4.2 mmol/L, and negative troponin T.
Admitted to Family Medicine inpatient service. Placed on O2 2 L/min via nasal prongs and started on furosemide (Lasix®) 40 mg IV BID. Home empagliflozin and perindopril held initially due to AKI. Net negative fluid balance of 3.2 L achieved over 72 hours. Weaned to room air on 14/05/2026 (SpO2 95 %). Cr improved to 98 µmol/L by 15/05/2026. Transitioned to oral furosemide and restarted home meds. Discharged in stable, euvolemic condition on 15/05/2026 at 11:00.
Medications at Discharge
- furosemide (Lasix®) 40 mg PO daily
- bisoprolol 5 mg PO daily
- perindopril (Coversyl®) 4 mg PO daily
- spironolactone (Aldactone®) 25 mg PO daily
- apixaban (Eliquis®) 5 mg PO BID
- empagliflozin (Jardiance®) 10 mg PO daily
- metformin (Glucophage®) 500 mg PO BID
Medication Changes During Hospital Stay
- INCREASED: furosemide (Lasix®) increased from 20 mg PO daily to 40 mg PO daily to maintain euvolemia.
Discharge Instructions
- Daily morning weights; restrict dietary sodium to < 2,000 mg/day and fluid intake to < 1.5 L/day.
- Outpatient lab requisition provided for electrolytes and creatinine in 5 days (20/05/2026).
- Follow up with primary care provider in 1 week.
- Return to ED if experiencing worsening SOB, chest pain, syncope, or weight gain > 1 kg in 24 hours or > 2 kg in 1 week.
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.