What is the current medical status of the patient?

Patient Summary for Provider Communication

To effectively communicate a patient's current medical status to another provider, create a structured medical transfer summary that includes current medications, recent clinical events, active medical issues, and immediate care needs. 1

Essential Components of Patient Summary

Core Information to Include

The medical transfer summary should contain at minimum:

• Current medication schedule with exact dosages - This is the single most critical element to prevent medication errors during transitions of care 1
• Active diagnoses and current health care issues - Document all ongoing medical conditions requiring management 1
• Recent clinical events - Include any episodes requiring immediate attention (e.g., hypoglycemia, acute decompensation, recent procedures) 1
• Vital signs stability status - Confirm whether the patient is medically stable 1
• Functional status and ADL dependencies - Specify exact assistance needs rather than vague terms like "needs help" 2

Medical Stability Assessment

Document the following to establish medical stability:

• Confirmed diagnosis with clarified etiology (though mechanism may still be under investigation) 1
• All acute disease processes have been addressed or have a clear follow-up plan 1
• Vital signs are stable at time of transfer 1
• Medical investigations completed or follow-up appointments scheduled 1

Factors Requiring Immediate Attention

Highlight any conditions indicating need for urgent management:

• Recent episodes of acute decompensation (hypoglycemia, respiratory distress, altered mental status) 1
• History of severe complications or frequent acute events 1
• Concurrent illnesses complicating primary condition 1
• Presence of complications from primary disease 1

Structured Format for Communication

Patient Identification and Context

• Patient demographics and contact information 1
• Reason for transfer or consultation 1
• Name and contact of sending provider for additional information 1

Current Clinical Status

Organize information hierarchically:

• Primary diagnosis with current disease severity 1
• Functional capacity - Use standardized terms: "Independent" (performs all ADLs without assistance), "Standby assist" (needs someone nearby for safety), or "ADL-dependent" (requires physical assistance from another person) 2
• Symptom burden - Quantify when possible (e.g., dyspnea severity, pain scores) 1
• Recent trajectory - Stable vs. deteriorating vs. improving 1

Medication Reconciliation

Provide complete medication list including:

• Drug names (generic and brand if relevant) 1
• Exact dosages and frequencies 1
• Route of administration 1
• Recent changes or adjustments 3

Pending Issues and Follow-up Needs

• Scheduled appointments the receiving provider must coordinate 1
• Outstanding test results or investigations 1
• Specific monitoring requirements 1

Common Pitfalls to Avoid

Do not use vague or ambiguous language:

• Avoid terms like "needs assistance" without specifying the exact ADL impairments and level of assistance required 2
• Do not simply state "multiple comorbidities" - list the specific active conditions 1
• Avoid retrospective assessment of health status - document current state only 1

Ensure medication continuity:

• Provide adequate medication supply to bridge until next appointment 1
• Include diabetes supplies and medications if applicable 1
• Document any medication allergies or intolerances 3

Address care coordination needs:

• If patient has complicated assessment needs or multiple comorbidities, explicitly state this 1
• Note if patient cannot attend outpatient services and requires home monitoring 1
• Identify if patient is older, living alone, or lacks support system 1

Documentation Standards

Use standardized assessment tools when quantifying functional status:

• Katz Index of Independence in ADLs for basic self-care activities 2
• IADL scales for complex activities (shopping, finances, medications) 2
• Clinical Frailty Scale for overall functional reserve 2

The summary should be reviewed by a healthcare provider upon receipt to ensure all critical information is understood and incorporated into the care plan 1.