Which History of Present Illness is appropriate for a Discharge - ProProfs Discuss
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Which History of Present Illness is appropriate for a Discharge Summary?

Asked by Christopher, Last updated: Sep 19, 2022

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John Smith

John Smith

John Smith
John Smith

Answered Sep 08, 2016

67yo w with cad, kidney disease (creatinine 2.0) and htn presents with shortness of breath. pt developed a cough 3 days prior productive of yellow sputum. reports fevers and chills. no sick contacts. last hospitalized 3 years ago with cellulitis. no chest pain or hemoptysis. no tobacco history.-reason: the history of present illness (hpi) in a discharge summary should be brief. it is more akin to the history of a sign-out or pass-off. it should cover information related to the final diagnosis rather than your entire differential diagnoses. you can discuss other causes of shortness of breath that were ruled out later in the hospital course if indicated. the hpi of a discharge summary should be much shorter than the hpi of an admission note. also try to minimize (as best you can) the abbreviations in a discharge summary. a long list of abbreviations reads more like a math text book then an description of the patient. a discharge summary that is difficult to read is not helpful to the next caregiver or the patient.
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