DATE OF SERVICE:

DATE OF ADMISSION:

DATE OF DISCHARGE:

MOST RESPONSIBLE DIAGNOSIS:

PRE ADMIT COMORBIDITIES:

POST ADMIT COMORBIDITIES:

SECONDARY DIAGNOSIS:

PRINCIPAL PROCEDURE:

OTHER PROCEDURES:

DISCHARGE MEDICATIONS:

CLINICAL SUMMARY:

FOLLOW-UP PLAN/CARE:

Thank you for involving us in the care of this patient.

THANKS & SIGNOFF