Discharge Summary (Vascular Surgery)

Patient: [Full name, DOB, MRN]

Admission: [Date/time]

Discharge: [Date/time, Length of stay in days]

Attending Surgeon: [Name, credentials]

Discharging Service: Vascular Surgery

Disposition: [Home / SNF / Inpatient Rehab / LTACH / Other: specify]

Discharge Summary Highlights

• Primary discharge diagnosis: [Index vascular condition]
• Major procedure(s): [Procedure name(s), date(s), laterality]
• Key complications or events: [Bleeding requiring transfusion / Graft or stent thrombosis / AKI / Infection / Stroke or TIA / None] (Explicitly state "None" if no major events occurred)
• Antithrombotic plan: [REQUIRED: Agent(s), indication, dose, duration, monitoring, managing clinician]
• Wound status: [REQUIRED if incision present: Status, closure type, removal timing and responsible clinician]
• Follow-up imaging: [REQUIRED: Modality, target anatomy, timing, ordering service]
• Pending results: [Test, expected completion, named owner] (State "None" if no pending results)
• Return precautions: [Key red flags; Clinic phone; After-hours contact]

(Do not finalize note until all REQUIRED placeholders are completed.)

Reason for Hospitalization

[Presenting problem and indication for hospitalization or procedure, including relevant preoperative context affecting discharge planning such as baseline functional status, prior antithrombotics, dialysis dependence, or prior vascular interventions] (2–4 sentences)

Discharge Diagnoses

• Primary: [Postoperative diagnosis or index vascular diagnosis]
• [Secondary diagnoses addressed during admission]
• [Clinically significant chronic conditions affecting post-discharge care]
• [Complication: specify] (Label explicitly as complication if applicable)

Procedures and Operations

Date	Procedure	Approach	Target Vessel and Laterality	Conduit or Device	Surgeon(s)	Outcome
[Date]	[Procedure name]	[open / endovascular / hybrid]	[Vessel(s) and side]	[Conduit or device type/size]	[Surgeon(s)]	[Technical success / outcome]

Operative synopsis: [Indication, key anatomic findings, and brief procedural summary]

• Endovascular details: [Access site(s), closure method, devices deployed, contrast volume if renal risk, access complications] (Include if endovascular or hybrid)
• Open surgery details: [Incision location(s), conduit or patch material, anastomosis targets, drains placed] (Include if open or hybrid)
• Intraoperative issues: [Complications, unplanned return to OR, conversions, or "None"]

(If no procedures performed, state: "No procedures performed during this hospitalization.")

Hospital Course

(Organize by problem in order of severity. Include vascular-specific content as applicable: index procedure outcome and limb perfusion status; bleeding, transfusion, or hematoma; thrombosis or reintervention; cardiac events, stroke/TIA, or delirium; AKI or contrast nephropathy; wound complications; pain control and mobility; diabetes management for CLTI. Explicitly document any complication, transfusion, return to OR, ICU transfer, confirmed infection, or adverse drug reaction.)

[Problem title with status, e.g., "Left fem-pop bypass POD#3 - stable"]

• Key events: [Brief chronology of interventions and clinical trajectory]
• Status at discharge: [Objective findings including pulses/signals, warmth, neurologic exam if relevant]
• Follow-up needs: [Specific tests, imaging, or monitoring required]

(Repeat subsection for each active problem)

Condition at Discharge

[Overall condition and functional status, e.g., stable, improved; ambulatory status; assistance needs]

• Vital signs: [Stable; afebrile or temperature]
• Cardiopulmonary: [Status; oxygen requirement if any]
• Vascular exam: [Distal pulses (palpable vs Doppler), limb warmth, capillary refill, motor/sensory, access site status]
• Wounds/incisions: [Appearance, drainage, erythema, edema]
• Drains/wound VAC: [Device type and status, or "None at discharge"]

Disposition and Services

• Discharge destination: [Home / SNF / Inpatient Rehab / LTACH]
• Home health services: [Wound care / PT / OT / Medication management / INR monitoring / None required]
• DME: [Walker / Wheelchair / Offloading footwear / Wound VAC supplies / Compression / None]
• Lines, drains, devices: [Type, location, responsible service, removal plan, or "None at discharge"]

Discharge Medications

Medication	Dose/Route/Frequency	Indication	Duration or Stop Date	Monitoring
[Medication name]	[Dose/Route/Frequency]	[Indication]	[Duration or stop date]	[Monitoring requirements]

Medication Changes: [New medications with rationale; dose changes with rationale; discontinued home medications with rationale]

Antithrombotic Regimen

• Antiplatelet therapy: [Agent(s), dose, frequency, indication (post-stent / PAD secondary prevention / carotid), duration]
• Anticoagulant therapy: [Agent, dose, indication (AF / VTE / graft thrombosis risk), renal dosing considerations, duration, monitoring plan]
• Combination therapy: [If applicable: bleeding risk counseling, gastroprotection strategy, clinician managing de-escalation]

(If no antithrombotic therapy, explicitly state rationale: active bleeding, allergy, high bleeding risk. Do not rely on medication list alone to convey the plan.)

Follow-up

Service/Provider	Purpose	Date/Time or Window	Location	Scheduling Responsibility
Vascular Surgery	[Postoperative review and surveillance]	[Date/time or window]	[Clinic/location]	[Responsible party]
[Anticoagulation Clinic if applicable]	[INR or DOAC monitoring]	[Date/time or window]	[Clinic/location]	[Responsible party]

Vascular Surveillance Plan

Near-term studies (0–90 days):

• [Modality (duplex / CTA / MRA / ABI)], [Target anatomy], [Due date window], [Clinical question], [Ordering service], [Imaging constraints if any]

Longitudinal surveillance: [Procedure-specific schedule: baseline study timing, frequency years 1–2, frequency beyond year 2] (Indicate if surgeon-confirmed or provisional pending clinic confirmation)

Triggers for earlier evaluation: [New symptoms, abnormal ABI, wound deterioration, sac enlargement, loss of pulse signal]

Pending Results

• [Test name, date obtained] — Expected: [Date] — Significance: [Brief clinical relevance] — Owner: [Named clinician/service] — Plan: [Communication method]

(If none, state: "No pending tests or results at discharge.")

Wound and Incision Care

[Site: Location and closure type]

• Dressing: [Type]; Changes: [Frequency]; Showering: [Guidance]
• Activity restrictions: [Site-specific restrictions]
• Warning signs: [Bleeding, expanding hematoma, infection signs, limb ischemia signs]
• Staple/suture removal: [Date/window, responsible clinician]

Drains or Wound VAC

• Device: [Type and settings if relevant]
• Dressing changes: [Frequency, responsible party (home health vs clinic)]
• Output monitoring: [Instructions, thresholds to call]
• Removal plan: [Criteria, responsible party]

(If not applicable, state: "No incision or wound care required.")

Activity and Lifestyle

• Activity restrictions: [Lifting limit, driving restrictions, return to work timing]
• Mobility: [Ambulation plan, assistive device use]
• Diet: [Cardiac / Renal / Diabetic / Regular]
• Hydration: [Recommendations if recent contrast or renal risk]
• Tobacco cessation: [Counseling provided, resources offered] (Include if applicable)
• Foot care: [Daily inspection, offloading instructions, footwear] (Include for PAD/CLTI/diabetes)

Return Precautions

Call 911 or go to ED immediately for:

• Stroke symptoms (sudden weakness, facial droop, speech difficulty, vision loss)
• Chest pain or severe shortness of breath
• Uncontrolled bleeding
• Sudden limb coldness, severe pain, numbness, or loss of function
• Syncope

Call clinic or on-call for:

• Fever, chills, wound drainage, redness, or increasing swelling
• Increasing pain at incision or access site
• Unusual bleeding or bruising
• Loss of pulse signal compared to discharge baseline

Contact: Clinic: [Phone] | After-hours: [On-call number]