Discharge Summary (ENT Surgery)

Patient: [Patient name] | DOB: [DOB] | MRN: [MRN] | Account/CSN: [Account/CSN]
Admission: [Admission date/time] | Discharge: [Discharge date/time]
Discharging Attending/Service: [Attending name, Service] | Primary Surgeon: [Primary surgeon name / Same as attending]
PCP: [PCP name / Unknown/Not on file]
Discharge Disposition: [Home / Home with services / SNF/Rehab / LTACH / Hospice / Transfer / AMA / Expired] (If Transfer, include receiving facility and accepting service; if unknown state "Not documented.")
Code Status at Discharge: [Full Code / DNR / DNI / DNR/DNI / Other]

Brief Summary

[One to three sentence summary including: patient age/sex and key comorbidities if relevant; principal ENT diagnosis and reason for admission; key procedure(s) with date(s); explicit statement of complications or "no complications"; discharge disposition; critical follow-up needs]

Diagnoses

Principal Discharge Diagnosis

[Principal diagnosis] (If uncertain pending pathology or workup, state uncertainty and reference Pending Results section.)

Secondary Diagnoses

• [Clinically active comorbidity or secondary condition] (Include conditions addressed during stay or affecting post-discharge care.)
• [Additional secondary diagnoses as applicable]

Procedures

• [Date] — [Procedure name with laterality and site]; Surgeon: [Name]; Implants/devices: [Trach tube type/size, drain locations, stents, packing, etc., or "None"]
• [Additional procedures including bedside procedures with setting and operator]

(If no procedures performed, state: "Procedures: None.")

Pertinent Findings

• [Key imaging, lab, culture, or pathology findings with brief interpretation]
• [Airway or swallow assessment outcomes if applicable]

(Include only clinically consequential results. Reference Pending Results for studies not finalized. Omit this section entirely if no significant findings warrant documentation.)

Consultations

• [Consulting service]: [Reason] — [Key recommendations influencing discharge]

(Omit this section if no consultations obtained.)

Hospital Course

[Brief narrative summary of hospitalization arc: presentation, key interventions/procedures, clinical response, and factors establishing discharge readiness]

1. [Index ENT surgical problem]

[Problem-focused summary: what was found, interventions performed, clinical response, discharge status, and remaining needs] (Address relevant domains such as airway status, bleeding/hemorrhage management, wound/flap status, drains/packing/stents, swallow and nutrition, pain control, infection/antibiotics, electrolytes/endocrine for thyroid/parathyroid cases. Include only applicable elements.)

2. [Additional active problem]

[Evaluation, treatment, response, discharge status, and monitoring needs for this problem]

(Add additional numbered problems as needed. Include only active or clinically relevant issues; do not include placeholder sections for non-applicable problems.)

Complications

Complications: [None / List complications with dates and management] (Always complete this field. Include surgical complications, hospital-acquired infections, medication/anesthesia adverse events, unplanned returns to OR or ICU escalations.)

Condition at Discharge

[Clinical status summary: hemodynamic stability, pain control adequacy, diet tolerance or tube feeding status, mobility/functional status, mental status if relevant. Include ENT-specific status: airway stability and oxygen needs, trach/stoma status, wound/incision appearance, drain status with recent output trend, swallow and voice status compared to baseline.]

Discharge Medications

Discharge medications were reconciled against the home medication list and inpatient MAR.

New

• [Medication] — [Dose, route, frequency, duration/stop date]; Indication: [Indication] (For high-risk medications: opioids—include quantity and bowel regimen; antibiotics—total duration and stop date; steroids—taper schedule; anticoagulants—restart date and bleeding considerations; calcium/vitamin D/thyroid hormone—monitoring plan.)

Changed

• [Medication] — [New regimen] (Changed from: [prior regimen]); Reason: [Reason]

Continued

• [Medication] — [Dose, route, frequency]

Stopped

• [Medication] — Reason: [Reason stopped or held]

(If no medication changes, state: "No medication changes from preadmission regimen.")

Allergies

[Allergen — Reaction type] (If none, state: "No known drug allergies.")

Discharge Instructions Provided

Discharge instructions were reviewed with [patient / family / caregiver] and understanding was confirmed. Topics covered: [diet, activity restrictions, wound care, drain care, airway/trach care, pain management, red-flag symptoms and return precautions, contact information—include only applicable domains]. (Note any barriers encountered such as language or literacy and interpreter use. For complex discharges involving airway, drains, or tube feeds, document who demonstrated competency and supplies confirmed. If education could not be completed, document the limitation.)

Follow-up Plan

Appointments

• ENT/Head & Neck Surgery: [Date/time/location] with [Surgeon/Clinic]
• PCP: [Scheduled appointment / Recommended within X days]
• [Other specialty follow-up as applicable: SLP, Endocrinology, Audiology, Oncology, Home Health]
• Post-discharge testing: [Test] due [Date/timeframe]

Pending Results

• [Study pending] — Expected: [Timeframe]; Responsible clinician: [Name/team]; Notification plan: [How patient/PCP will be informed]

(If none, state: "Pending results: None.")

Discharge Services and Equipment

• [Home health services: nursing, PT/OT, wound care]
• [DME and supplies: tracheostomy supplies, suction, humidification, tube feeding equipment, wound vac, drain supplies]
• [Special pharmacy or access considerations]

(Include only when applicable; omit this section entirely if no services or equipment arranged.)

Signature: [Author name, credentials/role] | [Date and time]

(If key clinical information cannot be determined, document explicitly as "Not documented" or "Unable to determine" rather than omitting.)