Can you provide a concise template for a surgical patient's History of Present Illness (HPI) and discharge summary, including demographics, past medical history, medications, allergies, social history, review of systems, physical exam, investigations, operative details, postoperative course, discharge plan, and follow‑up?

Surgical HPI and Discharge Summary Template

Use a structured, standardized format that includes all essential components to ensure safe transitions of care and clear communication with outpatient providers. 1, 2

History of Present Illness (HPI) Template

Patient Demographics & Presentation

• Age, sex, ethnicity, occupation, BMI (de-identified) 1, 2
• Mode of presentation: Specify whether patient arrived by ambulance, walked into emergency department, or was referred by family physician 1
• Chief complaint and presenting symptoms: Document the patient's main concerns in their own words 3

Past Medical & Surgical History

• Relevant past medical conditions with outcomes from previous interventions 1, 2
• Previous surgical history and any complications from prior procedures 1

Medications, Allergies & Social History

• Current medications with formulation, dosage, strength, route 1
• Drug allergies with specific reactions 3
• Smoking status, alcohol use, occupation 1
• Accommodation type, walking aids, functional status when relevant 1
• Family history including genetic information if applicable 1

Review of Systems & Physical Examination

• Pertinent positive and negative findings organized by system 3
• Vital signs and relevant physical exam findings presented systematically 1, 2

Diagnostic Workup

• Laboratory results, imaging studies, histopathology that led to diagnosis 1, 2
• Differential diagnoses considered and diagnostic reasoning 1
• Prognostic characteristics (e.g., tumor staging) when applicable 1

---

Discharge Summary Template

Hospital Course Section (Most Important)

This should appear first and be concise 4. Include:

• Admission date and reason for admission 5
• Primary and secondary diagnoses at discharge 4
• Brief hospital course: Key events in chronological order, complications encountered, and how they were managed 1, 6
• Timeline of significant events (consider using a table for complex cases) 1, 3

Surgical Intervention Details

• Procedure performed with date 5
• Surgical approach and technique: Anesthesia type, patient positioning, equipment used, sutures, devices, manufacturer and model of any implants 1
• Operator experience level and any modifications to standard technique 1, 3
• Intraoperative findings and any changes to planned procedure with rationale 1
• Estimated blood loss, operative time 1
• Complications (if any) categorized by Clavien-Dindo Classification 1

Pre-operative Optimization

• Patient optimization measures: Treatment of hypothermia/hypovolemia/hypotension, ICU care for sepsis, management of anticoagulation 1
• Concurrent treatments: Antibiotics, analgesia, anti-emetics, VTE prophylaxis 1

Post-operative Course

• Daily progress notes highlighting key recovery milestones 6
• Complications or adverse events with detailed management and outcomes 1
• Wound status at discharge 5
• Functional status and mobility at discharge 7

Medication Reconciliation (Critical Section)

This is ranked as one of the most important sections by primary care clinicians 4. Include:

• Complete list of discharge medications with formulation, dosage, strength, route, duration 1
• New medications started with indication 4
• Medications discontinued or changed with clear explanation 4, 6
• Medication adherence instructions 1

Discharge Plan & Instructions

• Discharge disposition: Home, rehabilitation facility, skilled nursing facility 6
• Activity restrictions: Weight-bearing status, lifting restrictions, return to work timeline 7, 5
• Wound care instructions: Dressing changes, drain management, clip/staple removal date and location 5
• Diet recommendations 6
• Return precautions: Specific symptoms requiring immediate medical attention 6

Follow-up Plan (Frequently Omitted - Ensure Inclusion)

This is the most commonly missing element in discharge summaries 5. Include:

• Follow-up appointments: Specific dates, times, locations, and which provider 1, 4
• Pending test results that require follow-up 4
• Future surveillance requirements: Imaging surveillance, clinical exams, laboratory monitoring with specific timeframes 1
• Specific post-operative instructions: Drain removal, suture/staple removal dates 7, 5
• Contact information for surgical team if questions arise 7

---

Key Formatting Principles

Prioritize High-Yield Content

• Place most important information first: Hospital course, discharge diagnoses, medication reconciliation, and follow-up sections should be at the beginning 4
• Be brief and succinct: Primary care clinicians have limited time to review discharge summaries 4
• Avoid excessive or inappropriate information that clutters the document 5

Ensure Chronological Organization

Presenting information in non-chronological order confuses readers 2, 3. Use a timeline or table for complex cases 1, 3

Common Pitfalls to Avoid

• Missing follow-up details: This is the most frequently omitted element 5
• Unclear medication changes: Explicitly state what was started, stopped, or modified 4
• Excessive length without key information: Quality improves as length decreases 8
• Lack of specific return precautions: Patients need clear guidance on when to seek care 6
• Omitting contact information for the surgical team 7

Documentation Standards

• Obtain informed consent for any case reports 2, 9
• De-identify all patient information in formal case reports 1, 2
• Use standardized frameworks (such as SCARE guidelines for surgical case reports or "DISCHARGED" framework for discharge summaries) 1, 6
• Include patient perspective when appropriate 2, 9

Quality Improvement

Frequent interventions and supervision are needed to maintain quality 8. Consider:

• Automated forms with essential data points integrated into electronic health records 5, 8
• Regular training and feedback for junior physicians who write most discharge summaries 6, 8
• Interdisciplinary collaboration between surgical teams and primary care to identify priorities 7, 4