4.1.12 Patient-related reports, doctor's letter Estimated reading: 1 minute 595 views Authors Download the VA as PDF Download Goal and purpose Reports should be forwarded in a timely manner to the departments inside and outside the hospital that are responsible for the patient's treatment or care. As a summarising document, the discharge letter is of great communicative importance. Rules must be established for its content and technical preparation. The report should always contain the reason for the patient's admission or referral, the diagnosis, the examinations and treatment procedures carried out and their results, the medication prescriptions and a description of the patient's state of health at the time of referral. The discharge letter should also include the concomitant illnesses, the medication taken during the hospitalisation, a description of the course of the illness and a description of the patient's condition on discharge (improved, unchanged), recommendations for further treatment and a plan for follow-up. The discharge letter (epicrisis) must be drawn up by an appropriately qualified person. Application Description of the process Risks Resources Material Time required Documentation Responsibility and qualification Notes and comments Applicable documents Validation documents Terms Attachments Form for a doctor's letterDownload Sample for a doctor's letterDownload 4.1 Documentation - Previous 4.1.11 OP report Next - 4.1 Documentation 4.1.13 Classification systems
