Pediatric Surgery Discharge Summary

Patient Name: [Patient full name] MRN: [MRN] DOB: [DOB] Age: [Age] Sex: [Sex]

Admission Date: [Admission date] Discharge Date: [Discharge date] Length of Stay: [Length of stay]

Discharge Weight (kg): [Discharge weight in kg] (Include dosing weight if different and clinically relevant.)

Attending Surgeon: [Attending surgeon] Discharging Clinician: [Discharging clinician]

PCP: [PCP name and contact information] (If not on file, state "Not on file.")

Reason for Hospitalization

[One- to two-sentence summary explaining the reason for admission, whether for operative vs nonoperative management, and critical baseline factors influencing care decisions such as prematurity, congenital anomalies, or key comorbidities]

Discharge Diagnoses

• [Principal discharge diagnosis]
• [Secondary diagnoses and comorbidities addressed during admission]

(List only diagnoses that required evaluation/treatment, changed management, or require outpatient follow-up. Order by clinical importance. Note if postoperative diagnosis differs from preoperative diagnosis. Label suspected but unconfirmed diagnoses as "Possible [diagnosis] – workup incomplete, see Pending Studies.")

Procedures

• [Date] – [Procedure name] ([open / laparoscopic / robotic]) – [Laterality/site]. [Key intraoperative findings relevant to follow-up]. Specimens: [type, final / pending]. [Drains or lines placed]. Intraoperative complications: [none / description].

(One line per procedure. Do not duplicate the full operative note. If no procedures were performed, state "No procedures performed during this hospitalization.")

Consultations

• [Consulting service] – [Primary reason for consult]. Follow-up: [Consult-driven follow-up needed after discharge].

(Omit this section entirely if no consultations occurred.)

Pertinent Findings

• Imaging: [Modality] [date] – [Key result relevant to follow-up]
• Microbiology: [Specimen/test] [date] – [Key result]
• Pathology: [Specimen] [date] – [Final diagnosis]
• Laboratory trends: [Brief trend summary, e.g., WBC improved from X to Y by discharge]

(Include only findings that affect discharge care or follow-up. Do not include pending results here. Omit this section entirely if no pertinent findings warrant documentation.)

Hospital Course

(Use chronological format for straightforward postoperative stays or problem-oriented format for complex admissions. Delete the unused format. Always address: indication for surgery or reason for nonoperative management, key perioperative events, postoperative milestones achieved, complications encountered with management, deviations from expected course with rationale, and criteria for discharge readiness.)

Chronological Milestones

• Preoperative status: [Brief baseline status and indication for surgery]
• Operative day: [Key intraoperative and perioperative events]
• Postoperative course: [Extubation, pain control transitions, diet advancement and tolerance, bowel and voiding function, mobilization, drain and line management]
• Discharge readiness: [Criteria met and timing]

Problem-Oriented Summary

• Surgical problem: [Diagnosis, operative vs nonoperative rationale, key events, current status]
• Pain management: [Strategy, transitions, response]
• Nutrition/feeding: [Route, formula or diet, advancement, tolerance]
• Infection/antibiotics: [Source, cultures, antibiotic regimen with dates, response]
• Respiratory status: [Support, weaning, significant events]
• Lines/drains/tubes: [Types, course, removals, rationale if remaining]
• Other active issues: [Comorbidity or complication management]

Complications

• [Date] – [Complication description]. Management: [Management]. Status at discharge: [Status].

(Always include this section. If no complications occurred, state "None.")

Condition at Discharge

• Overall status: [stable / improved / unchanged / worsened]
• Functional status: [Age-appropriate functional status at discharge]
• Pain control: [oral / IV / regional / other] – [adequate / inadequate]
• Diet/feeding: [Diet type or feeding plan, tolerance]
• Wound/incision: [Location, appearance, dressing status]
• Devices remaining: [Device type, location, indication, care requirements, planned removal timing, responsible clinician] (Include only if applicable.)

(Base on documented discharge-day assessment; do not infer.)

Disposition

Discharge destination: [home / home with services / inpatient rehabilitation / transfer to another facility]

• Home services arranged: [Home nursing / infusion pharmacy / enteral supply company / none]
• Durable medical equipment: [Items provided or "None"]

Discharge Medications

Medication allergies: [Allergies and reactions, or "No known drug allergies"]

New medications started

• [Generic name] – [dose with weight-based calculation if applicable] – [route] – [frequency] – [indication] – [duration or stop date]

Medications changed

• [Generic name] – [what changed] – [new dose and schedule] – [indication] – [duration or stop date]

Medications continued unchanged

• [Generic name] – [dose] – [route] – [frequency] – [indication]

Medications stopped

• [Generic name] – [reason stopped]

(For antibiotics, always specify indication and stop date. For opioids, include bowel regimen. For PRN medications, include reason and maximum frequency.)

Discharge Plan

Diet/Feeding

[Diet or feeding plan with restrictions or advancement instructions]

Activity

[Activity restrictions: lifting limits, return to sports/playground, school/daycare guidance with timelines]

Wound Care

[Dressing changes, bathing restrictions, signs of infection to monitor]

Device Care

[Care instructions for drains, ostomy, tubes, or lines including troubleshooting and output monitoring] (Include only if applicable.)

Pain Management at Home

[Home analgesic plan: scheduled vs PRN, taper if applicable, bowel regimen if opioids prescribed]

Return Precautions

• Fever ≥ [38.0°C / 100.4°F or as specified]
• Wound concerns: redness, drainage, swelling, dehiscence
• Vomiting or inability to tolerate feeds
• Decreased urine output
• Respiratory distress or increased work of breathing
• Uncontrolled pain despite medications
• Device problems: blockage, leak, malfunction, or dislodgement

Contact Information

24/7 Pediatric Surgery: [Phone number] Clinic: [Phone number]

Follow-Up

• Pediatric Surgery clinic: [Appointment date/time, or timeframe and scheduling mechanism]
• PCP: [Timeframe for post-hospital follow-up]
• Subspecialty follow-ups: [Service – timeframe – scheduling mechanism] (Include only if applicable.)
• Outpatient labs/imaging: [Test – timing – who will review results] (Include only if applicable.)
• Suture/staple/drain removal: [What – by whom – timing] (Include only if applicable.)

Pending Studies

• [Study pending] – [date obtained] – [clinical significance] – [responsible clinician for follow-up] – [how family will be notified]

(Always include this section. If nothing is pending, state "None.")

Immunizations

• [Vaccine name] – [date administered]

(Omit this section entirely if no immunizations were given during hospitalization.)