Cardiology Discharge Summary

Patient Name: [Patient full name]

MRN: [Medical record number]

Date of Birth / Age: [DOB] / [Age]

Sex: [Sex]

Admission Date/Time: [Admission date and time]

Discharge Date/Time: [Discharge date and time]

Admitting Service: [Admitting service]

Discharging Service: [Discharging service]

Attending of Record: [Attending physician name]

Primary Inpatient Cardiology Team: [Inpatient cardiology team]

Discharge Disposition: [Home / Home with services / Acute rehab / SNF / LTACH / Other]

Primary Care Physician: [PCP name or "unknown/not on file"]

Primary Outpatient Cardiologist: [Cardiologist name or "unknown/not on file"]

Brief Summary

[1–3 sentence synopsis: reason for hospitalization, key cardiac diagnosis(es) and major interventions, discharge clinical state and destination]

Discharge Diagnoses

• [Principal cardiac diagnosis] (If uncertainty remains, label as "Working diagnosis at discharge" with supporting evidence and planned follow-up.)
• [Secondary active problems addressed during stay]
• [Clinically relevant chronic conditions that impacted management]

(Order by clinical importance. Do not auto-populate the entire problem list.)

Significant Findings / Pertinent Results

• Cardiac testing: [Echocardiogram with date, LVEF, key structural findings; stress testing modality and result; coronary angiography/PCI with key lesions and interventions; clinically important telemetry events] (If LV function was not assessed, document the outpatient plan.)
• Selected labs: [Peak and discharge troponin if ACS; BNP if HF; discharge creatinine/eGFR, K, Mg; hemoglobin/platelets if on antithrombotics]
• Imaging: [Decision-relevant imaging findings only]

(Include only results that changed management or explain clinical decisions. Omit routine daily trends.)

Procedures

• [Date] – [Procedure]: [Key details, outcome, complications if any] (Include target vessel and stent type for PCI; device type/model for PPM/ICD/CRT.)

(Omit entire section if no procedures were performed.)

Consultations

• [Consulting service]: [Actionable recommendation impacting discharge plan]

(Include only consultations whose recommendations alter the discharge plan. Omit section if not applicable.)

Hospital Course by Problem

(Use numbered problem-oriented headings ordered by severity and relevance to admission. For each problem, document the final assessment with supporting data, key interventions and response, clinical trajectory, status at discharge, and specific follow-up actions with timeframes and responsible clinician. If etiology is suspected but unproven, label as such and specify required follow-up.)

1) [Problem title / diagnosis]

Assessment: [Diagnosis with key supporting data and clinical reasoning]

• Key interventions and response: [Therapies, procedures, medication changes; patient response]
• Clinical trajectory: [improved / stable / worsened]
• Status at discharge: [Current symptoms/signs and objective status]
• Follow-up plan: [Specific actions, timeframe, responsible clinician/service]

2) [Additional problems as applicable]

(Repeat structure above for each problem. Omit empty headings.)

Cardiology-specific content to incorporate within relevant problems:

• ACS/CAD/PCI: MI type, coronary anatomy, intervention, DAPT plan with duration, secondary prevention (statin intensity, beta-blocker, ACEi/ARB/ARNI), cardiac rehab referral
• Heart failure: HF phenotype and EF, volume status, diuretic strategy, GDMT changes with rationale and titration plan, electrolyte/renal monitoring, follow-up timing
• Arrhythmia/EP: Rhythm at discharge, rate/rhythm control strategy, anticoagulation plan, device details and follow-up
• Valvular/structural: Severity, inpatient evaluation, next testing/intervention plan
• AKI/CKD: Contrast exposure notes, follow-up renal monitoring
• Bleeding/anemia: Impact on antithrombotic choices, follow-up labs

Complications

• [Event and date]: [Management] – [Status at discharge]

(Include contrast nephropathy, access site hematoma, bleeding, arrhythmias requiring escalation, medication reactions. Omit entire section if no complications occurred.)

Condition at Discharge

[Overall condition: stable / improved / guarded]; [Symptoms at discharge]; [Functional status]; [Cognitive status if relevant to self-management]; [NYHA class if HF]; [Oxygen requirement if new]; [Rhythm status]

Disposition and Services

• Destination: [Home independently / Home with services / Acute rehab / SNF / Other]
• Home services: [Home health, PT, OT, nursing if applicable]
• DME: [Equipment and instructions if applicable]
• Wound/access care: [Device pocket or access site instructions if applicable]

Discharge Medications

(Provide clinician-authored reconciliation beyond the structured list. Include indication, rationale, planned duration, and monitoring for each change.)

New Medications Started

• [Medication, dose, schedule] – [Indication]; [Rationale]; [Duration/stop criteria]; [Monitoring plan and responsible clinician]

Dose/Frequency Changes

• [Medication, new dose/schedule] – [Indication]; [Rationale for change]; [Monitoring plan]

Medications Stopped or Held

• [Medication] – [Reason]; [If/when to restart]; [Who will reassess]

High-Risk Medications Requiring Monitoring

• Anticoagulant: [Agent, dose, indication, monitoring (INR plan if warfarin), bleeding precautions, responsible clinician]
• Antiplatelets: [DAPT plan and duration, indication, monitoring]
• Antiarrhythmic: [ECG/QTc and lab monitoring requirements, responsible clinician] (if applicable)
• Diuretics/RAASi/ARNI/MRA: [Renal function and potassium follow-up plan, titration plan, responsible clinician]

(If rationale for any change is unknown, document explicitly and specify who will reconcile.)

Anticoagulation / Antiplatelet Plan

• Indication(s): [Indication(s)]
• Agent(s) and dose(s): [Medication(s) with doses, schedule, start date]
• Planned duration: [End date or condition-based stop criteria]
• Peri-procedural instructions: [Hold instructions if applicable]
• Monitoring plan: [INR schedule for warfarin; renal function for DOAC; responsible clinician]
• Bleeding precautions: [Red flags and avoidance instructions, e.g., NSAIDs]

(Omit this section if no antithrombotics are prescribed.)

Pending Results and Follow-Up Responsibility

(If no tests are pending, state: "No pending tests at discharge.")

Test	Date Ordered	Clinical Question	Expected Timeframe	Responsible Clinician/Service	Action if Abnormal
[Test name]	[Date]	[Clinical question]	[Timeframe]	[Specific clinician or service]	[Action]

Follow-Up and Recommended Testing

• Scheduled appointments: [Cardiology clinic, date/time, purpose]; [EP/device clinic if applicable]; [PCP, date/time, key items to address]
• Recommended but not yet scheduled: [Item, intended timeframe, who will schedule]
• Laboratory monitoring: [Test, timeframe, reason, responsible clinician]
• Imaging/diagnostics: [TTE, stress test, Holter, device interrogation with timing and indication]
• Cardiac rehabilitation: [Enrollment status and instructions]

For Outpatient Clinicians – Priority Items:

• [Priority item #1 with timeframe]
• [Priority item #2 with timeframe]
• [Priority item #3 with timeframe]

Discharge Instructions (Clinician Summary)

• Return precautions: [Chest pain, syncope, worsening dyspnea, bleeding, other symptom-specific guidance]
• Activity restrictions: [Procedure/device-related restrictions and duration]
• Home monitoring: [BP, weight, pulse targets; thresholds for calling; who to contact]
• Medication adherence: [Critical therapies to emphasize]

(Keep concise; detailed patient education belongs in the After Visit Summary.)