Discharge Summary (Congenital Heart Disease)

Patient Name: [Patient full name]

DOB: [Date of birth]    MRN: [Medical record number]

Admission Date: [Admission date]    Discharge Date: [Discharge date]

Discharging Service: [Pediatric Cardiology / Adult Congenital Heart Disease (ACHD) / Cardiac Surgery / Other]

Attending Physician: [Attending physician name, credentials]

Primary Cardiologist: [Primary outpatient cardiologist and program]

Disposition: [Home / Acute rehab / SNF / Transfer / Other]

Reason for Hospitalization: [One-line reason for hospitalization]

CHD Snapshot (Anatomy/Physiology)

(Required section. If any information is unavailable, explicitly document "unknown" with source gap and plan to obtain records. Do not infer anatomy, surgical history, or hemodynamics.)

• Congenital Anatomy:
  • [Cardiac position and situs]
  • [Atrial and ventricular connections; AV and VA connections]
  • [Great vessel relationships and outflow anatomy; arch sidedness]
  • [Associated lesions: septal defects, obstructive lesions, collaterals, coronary anomalies]
  • [Current surgical state: patches, baffles, conduits, shunts, fenestrations, prosthetic valves with sizes]
  • [Plain-language interpretation] (Include only for complex anatomy.)
  • [Data gaps and plan to obtain outside records] (Include if applicable.)
• Surgical/Catheter History:

  (List chronologically. If date unknown, write "year unknown (childhood)" rather than estimating.)

  • [Date or age] – [Procedure name] – [Institution] – [Key details: conduit/valve/device types and sizes]
  • [Additional prior interventions]
  • [Unknown elements and plan to retrieve records]
• Current Physiology:
  • Baseline oxygen saturation: [xx–yy%] on [room air / home O2 with settings]
  • Discharge oxygenation: [Saturation %] on [room air / supplemental O2 with settings]
  • Ventricular function: [Systemic ventricle]; [Subpulmonic ventricle]
  • Valvular disease: [Valve and severity for significant lesions]
  • Pulmonary hypertension/PVR: [Present / Absent / Unknown; most recent PVR if known]
  • Shunt physiology: [Direction and significance if applicable]
  • Arrhythmia history/current rhythm: [History]; [Discharge rhythm]; [Device type if present]
  • End-organ status: [Renal]; [Hepatic]; [Hematologic]
• High-Risk Precautions:
  • Anticoagulation: [Indication]; [Agent]; [Target range]; [Bridging status if applicable]
  • Endocarditis prophylaxis: [Yes / No / Unknown] (If yes: [qualifying condition] and [regimen]. If unknown, state plan to clarify.)
  • MRI conditional status: [MRI-conditional / Not MRI-conditional / Unknown / No device] (If device present: [manufacturer, model, conditional settings].)

Discharge Diagnoses

Principal diagnosis: [Primary discharge diagnosis]

• [Secondary diagnosis 1]
• [Secondary diagnosis 2]
• [Additional diagnoses as applicable]

Hospitalization summary: [1–3 sentence summary of presenting symptoms and triggering event]

Procedures This Admission

(If none, write "None.")

• [Date] – [Procedure name] ([Operator/service])
  • Indication: [Indication]
  • Key findings:
    • [Finding 1]
    • [Finding 2]
    • [Finding 3]
  • Access/hemodynamics: [Access sites]; [Key pressures, gradients, PVR, Qp:Qs] (For catheterization.)
  • Implants/specs: [Conduit/valve/device type, size, settings] (If applicable.)
  • Complications: [None / Description]
• [Additional procedures as applicable]

Key Imaging & Hemodynamics

(Summarize decision-relevant highlights with dates; do not copy full reports. Omit modalities not performed.)

• Echocardiography: [Date]
  • [Systemic and subpulmonic ventricular function]
  • [Key valve lesions and severity]
  • [Gradients across repaired lesions/conduits]
  • [Shunt/baffle patency]
• Catheterization hemodynamics: [Date]; [Room air / Oxygen]
  • [RA, PA, wedge pressures]
  • [PVR with units if available]
  • [Qp:Qs if applicable]
  • [Significant gradients]
• CMR/CT: [Date]
  • [Ventricular volumes/function]
  • [Regurgitant fractions]
  • [Aortic and pulmonary artery findings]
  • [Conduit anatomy/patency]
• Rhythm:
  • [ECG interpretation with date]
  • [Telemetry summary] (If clinically meaningful.)
  • [Device interrogation: type, dependence, programmed mode, battery, notable events] (If applicable.)
• Labs (discharge-relevant):
  • [Renal function]; [Electrolytes]; [Hemoglobin/hematocrit]
  • [BNP/NT-proBNP] (If used for decision-making.)
  • [INR/anti-Xa with date] (If anticoagulated.)
  • [Liver function] (Especially for Fontan physiology.)

Hospital Course

(Organize by active problem in decreasing order of severity. Explicitly document complications and adverse drug reactions.)

[Problem 1]: [One-line summary]

• Key interventions & response: [Interventions and clinical response]
• Status at discharge: [Current status]
• Complications/adverse events: [None / Description]
• Consultant recommendations: [Summary]
• Ongoing plan: [Plan with follow-up reference]

[Problem 2]: [One-line summary]

• Key interventions & response: [Details]
• Status at discharge: [Details]
• Complications/adverse events: [None / Description]
• Consultant recommendations: [Summary]
• Ongoing plan: [Plan]

(Add additional problems as needed.)

Condition at Discharge

• Vitals: [Stable / Labile]; [Ranges if relevant]
• Oxygen requirement: [Room air / Supplemental O2 with settings]; [Target saturation]
• Weight/fluid status: [Discharge weight]; [Net fluid balance if relevant]
• Functional status vs baseline: [At baseline / Improved / Worse]; [Mobility/ADLs]
• Pain control: [Adequate / Inadequate]; [Regimen]
• Wound/access sites: [Status and care needs]
• Lines/drains/tubes: [Type]; [Care instructions]; [Removal plan] (If applicable.)

Discharge Medications

Reconciliation summary: [Changes from home regimen and rationale; high-risk medications first: anticoagulants, antiarrhythmics, diuretics, pulmonary vasodilators; explicitly note stopped medications]

Medication List

• [Medication (generic)] — [Dose] [Route], [Frequency]; Indication: [Indication]; Monitoring: [Plan]; [Stop date if time-limited]
• [Additional medications]

Anticoagulation details: [Agent]; [Indication]; [Target INR/anti-Xa]; [Next level date]; [Managing clinician]; [Bleeding precautions] (If applicable.)

Diuretic monitoring: [Weight threshold to call]; [Electrolyte monitoring schedule]; [Self-adjustment parameters if provided] (If applicable.)

Endocarditis prophylaxis: [Indicated / Not indicated / Uncertain] (If indicated: [Qualifying condition]; [Antibiotic regimen for dental procedures]. If uncertain, document plan to clarify.)

Activity, Diet & Care Instructions

• Activity: [As tolerated / Restrictions]; [Sternal precautions / Lifting limits / Access-site restrictions with duration]
• Return to work/school: [Timeframe and conditions]
• Diet: [Cardiac diet / Sodium restriction / Fluid restriction / Other]
• Wound care: [Dressing changes]; [Showering guidance]; [Signs of infection]
• Home therapies: [Home oxygen settings]; [Feeding tube regimen]; [Central line care] (If applicable.)

Red Flags / Return Precautions

(Individualize numeric thresholds based on patient baseline.)

Call cardiology same day if:

• Increasing cyanosis or sustained saturation below [patient-specific threshold]%
• Sustained palpitations or new irregular heartbeat
• New or worsening exertional symptoms
• Weight increase >[threshold] in 24–48 hours or worsening edema
• New fever, especially with cardiac device or central line
• Reduced oral intake or urine output (in infants)

Go to ED / call 911 if:

• Severe respiratory distress or oxygen saturation below [critical floor]%
• Chest pain with diaphoresis or syncope
• Uncontrolled bleeding while on anticoagulation
• Stroke symptoms: facial droop, arm weakness, speech difficulty
• Syncope or near-syncope

Follow-Up & Testing Plan

Appointments

• [Specialty/Provider]: [Timeframe]; [Purpose]; Status: [Scheduled for date/time / Needs scheduling by (responsible party)]
• [Additional appointments]

Ordered Tests

• [Test name]: [Timeframe]; [Ordering clinician]; Results to: [Team/clinician]
• [Additional tests]

CHD surveillance reminders: [Aortic imaging]; [RV surveillance for repaired ToF]; [Fontan cardiac/hepatic surveillance]; [Pulmonary hypertension follow-up]; [Device clinic] (Include as applicable.)

Pending Items

(If none, write "None.")

• [Pending item] — Expected: [Date]; Responsible: [Clinician/team]; Patient notification: [Method]
• [Additional pending items]

Care Team & Contact Information

• CHD program contact: [Phone number] [24/7 if available]
• Backup contact: [Alternative numbers/after-hours pathway]
• Accepting outpatient clinicians: [Primary care]; [Primary cardiologist/ACHD]; [Other specialists]