Table 2 Final Items in the Medical Discharge Summary Section of the D-SAFE Model
1. Reason for admission |
2. Main diagnosis and other active diagnoses (specify if: allergy, chronic pain, tobacco, alcohol) |
3. Non-active diagnoses |
4.Social and life-style history upon admission (marital status, household arrangements, guaranteed income supplement, legal protection measures, services received, etc.) |
5. Pertinent findings of the medical history-taking or the physical exam (specifically, vision, audition, musculoskeletal, and neurological) |
6. Investigations and consultations (labs, imaging, other) - indicate if copies of the reports are annexed to the document |
7. Mental functions |
   7.1. Cognitive status |
   7.2. Affective status |
   7.3. Neurobehavioral symptoms associated with dementia |
   7.4. Facultative: MMSE, MOCA, CASE, Geriatric depression scale (GDS) |
8. Functional status - indicate if copies of the reports are annexed to the document |
   8.1. Activities of daily living |
   8.2. Instrumental activities of daily living |
   8.3. Urinary or fecal incontinence |
   8.4. Mobility/transfer |
   8.5. Technical support |
   8.6. Facultative: Walking speed, Timed «Up & Go», Berg score |
9. Nutritional status indicate if copies of the reports are annexed to the document |
   9.1. Actual weight |
   9.1. Height |
   9.3. Weight variation in the past 6 months |
   9.4. Dysphagia |
   9.5. Other |
10. Psychosocial assessment - indicate if copies of the reports are annexed to the document |
11. Evolution of clinical problems during hospitalization |
12. Instructions at discharge and follow-up |
   12.1 Medical services (specialists' names, if known) |
   12.2. Professional care and services |
12.2.1. Nurse |
12.2.2. Physical therapist |
12.2.3. Occupational therapist |
12.2.4. Social worker |
12.2.5. Dietician |
12.2.6. Pharmacist |
12.2.7. Respiratory therapist |
12.2.8. Foot care |
   12.3 Programs |
12.3.1 Day center |
12.3.2 Day hospital |
12.3.3 Gerontopsychiatry |
12.3.4 Palliative care |
12.3.5 Functional and intensive rehabilitation |
12.3.6 Other |
   12.4 Home support services |
12.4.1 Household help |
12.4.2 Help with meal preparation |
12.4.3 Help with errands |
12.4.4 Meals on wheels |
12.4.5 Accompaniment service |
12.4.6 Friendship visits |
12.4.7 Orderly support for personal hygiene |
12.4.8 Other |
   12.5 Services for natural caregivers |
12.5.1 Respite |
12.5.2 Information/counselling service |
12.5.3 Psychosocial services |
12.5.4 Support groups |
12.5.5 Other |
   12.6 Technical support |
12.6.1 Orthotics or prosthetics |
12.6.2 Walker |
12.6.3 Cane |
12.6.4 Wheelchair |
12.6.5 Special equipment (bars...) |
12.6.6 Incontinence protection |
12.6.7 Other |
13. Patient orientation |
   12.1. Place of residence |
   12.2. Relocation (type of structure, name of the establishment, if known) |
14. Additional notes |
15. Signature of primary hospital physician (name in print, licence number, date) |
16. Name of family physician |
17. CLSC attended (name of establishment, name of case manager) |
18. Resource-person (name, relationship with the patient, phone number) |
19. Copy given to |
   19.1. Patient |
   19.2. Name of physician or establishment |