Discharge Summary (OMFS)

(Omit any field line if the information is not available from the encounter.)

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Admission Date: [Admission date]

Discharge Date: [Discharge date]

Discharge Disposition: [home / skilled nursing facility / inpatient rehab / acute transfer / against medical advice / hospice / other]

Attending Surgeon: [Attending surgeon name, credentials]

Service: Oral & Maxillofacial Surgery

Discharge Diagnosis and Summary

[Discharge synopsis in 3–5 sentences integrating: primary discharge diagnosis using OMFS terminology; reason for hospitalization with presenting symptoms and high-risk features; key secondary diagnoses or comorbidities affecting care; principal procedure with date if performed; and discharge status indicators including diet tolerance, pain control, temperature, airway status, occlusion/MMF/elastic status, and drain status]

Pertinent History

(Include this section only if elements materially affect discharge care. Omit entirely if not applicable.)

• Allergies/adverse reactions: [Relevant allergies with specific reactions; verification status] (If allergy status could not be confirmed, document unconfirmed status and mitigation steps taken.)
• Comorbidities impacting healing or infection risk: [Relevant conditions such as diabetes, immunosuppression, smoking status, malnutrition, prior radiation]
• Anticoagulation/antiplatelet therapy: [Agent(s), last dose, perioperative management, bridging if used, restart plan with timing]
• Social/functional considerations: [Home support, transportation, ability to perform wound/oral care, substance use considerations]

Hospital Course

(Organize by clinical problem using H3 subheadings below. Include only sections relevant to this patient's hospitalization. Order by clinical acuity and importance.)

Airway Management

(Include only if airway management was a clinical issue.)

[Initial airway presentation; interventions such as intubation approach or tracheostomy; perioperative course; current airway status at discharge]

• Procedure: [Name; date; approach; devices/hardware; drains] (Reference that full operative report is available.)
• Pending items: [What is pending; expected timeframe; responsible party for review and patient notification]

Facial Fractures – [Anatomic region]

(Include for each involved region as applicable: mandible, maxilla/Le Fort, ZMC, orbital, nasal, frontal sinus. Repeat this subsection for multiple regions.)

[Presentation and imaging-confirmed injuries; key findings guiding management; interventions including reduction/fixation; occlusion status; current status at discharge]

• Procedure: [Name; date; intraoral vs extraoral approach; fixation/hardware; arch bars/MMF status; teeth extracted; drains] (Reference that full operative report is available.)
• Pending items: [What is pending; timeframe; responsible party for follow-up and notification]

Odontogenic or Deep Neck Space Infection

(Include only if infection was a clinical issue.)

[Source tooth/space(s) involved; clinical and imaging findings; airway risk assessment; incision and drainage/extractions performed; culture data and antibiotic course; clinical response; current status at discharge]

• Procedure: [I&D/extractions; date; approach; drains placed; specimens sent] (Reference that full operative report is available.)
• Microbiology: [Specimen source; collection date; organism(s) and susceptibilities if resulted; culture-directed vs empiric therapy]
• Pending items: [What is pending; timeframe; responsible party for follow-up and notification]

Pain Management

[Analgesic strategy during admission including multimodal components and nerve blocks if used; response; adverse effects if any; discharge pain control status and plan]

Nutrition

[Dietary progression; swallow safety; nutrition/SLP involvement if applicable; enteral access if used; discharge diet tolerance and plan]

Postoperative Complications

(Include only if complications occurred.)

[Complication type such as bleeding, infection, malocclusion, hardware concerns, or neuropathy; evaluations performed; interventions; current status at discharge]

Condition at Discharge

• General/vitals: [Mental status; hemodynamic stability; temperature; oxygen requirement if any]
• Airway/respiratory: [Airway patency; stridor if present; tracheostomy status; suctioning needs]
• Pain and oral intake: [Pain control adequacy; diet tolerance; hydration status]
• Wounds/incisions: [Location; appearance; drainage amount and quality; dressing type; suture/staple status]
• Intraoral findings/occlusion: [Occlusion relative to premorbid; MMF/elastic configuration; mucosal healing; intraoral incision status]
• Cranial nerves: [CN V2/V3 sensation with paresthesia location/degree if present; CN VII motor function; other deficits]
• Devices in place: [Arch bars/MMF; drains; feeding tube; PICC; tracheostomy; elastics] (Include care and removal plan.)

Discharge Medications

Medication changes:

• Started: [New medications]
• Stopped: [Discontinued medications with reason if clinically relevant]
• Dose changes: [Modified medications]

Reconciled discharge medication list:

• [Medication name] — [Dose] [Route], [Frequency]. [Indication]. [Duration/stop date if time-limited]

Antibiotic stewardship: (Include if antibiotics prescribed.) Agent: [agent]; Indication: [indication]; Start: [date]; Planned end: [date]; [culture-directed / empiric]

(If opioid prescribed, include bowel regimen. If any medication details could not be confirmed, document gap and instruct patient to verify with pharmacy or PCP.)

Discharge Instructions

(Provide patient-facing, plain-language instructions. Include only applicable sections.)

Diet

• [Diet consistency: liquid / full liquid / soft / no-chew; caloric and hydration guidance; how to advance diet if applicable]

Wound Care

• [Dressing change frequency and technique; showering instructions; topical agents; suture/staple removal timing]

Oral Hygiene

• [Brushing modifications; rinses such as chlorhexidine with dosing and duration; irrigation instructions if applicable]

Jaw Fixation Care

(Include only if MMF, arch bars, or elastics in place.)

• [Elastic wear schedule; instructions if bands break; oral hygiene around hardware; emergency wire cutter guidance if applicable]

Sinus Precautions

(Include only if maxillary sinus involvement.)

• [No nose blowing; sneeze with mouth open; avoid straws; duration of precautions]

Activity

• [Lifting restrictions; no contact sports; head elevation requirements; return-to-work/school guidance]

Medications

• [Antibiotic completion instructions; pain regimen sequencing; maximum daily acetaminophen reminder; bowel regimen if taking opioids]

Warning Signs — Seek Immediate Care If:

• Increasing facial or neck swelling or firmness
• Fever or chills
• Worsening pain not controlled by medications
• Bleeding that does not stop with pressure
• Difficulty breathing, noisy breathing, or stridor
• Inability to tolerate oral intake or persistent vomiting (especially with jaw fixation)
• New vision changes, severe headache, or clear fluid from nose/ears concerning for CSF leak

Follow-up Plan

Scheduled appointments:

• [Date – Time – Location – Service – Purpose such as wound check, suture removal, hardware evaluation, occlusion assessment]

Pending Results:

• [Item pending] – [Expected timeframe] – [Responsible party for review] – [How patient will be notified]

Post-discharge labs/studies: (Include if applicable.)

• [Task] – [Timing] – [Responsible party to order, review, and act on results]

Primary care: [PCP name and contact] (If no established PCP, document and provide guidance on establishing primary care.)

Attending Surgeon Signature: [Name, credentials, date/time]