Name of Patient - Age - Roon / Ward - Hospital No. - Sex

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HSP-010-NUR-0

PIDDIG DISTRICT HOSPITAL


Piddig, Ilocos Norte

Name of Patient _____________________________ Age ____ Sex _________


Roon / Ward _______________________ Hospital No. ______________

DISCHARGE SUMMARY

Date Admitted: _____________________________________________________________________________

Admitting Diagnosis: ________________________________________________________________________


Final Diagnosis: ____________________________________________________________________________
Chief Complaint: ___________________________________________________________________________

Brief Clinical History and Pertinent Physical Examination:


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Laboratory Findings: (Including ECG, X-Ray and other Diagnostic Procedures)


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Course in the Ward: (Include medication)


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Disposition: (Indicate home medications, special-instruction and follow-up)


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