Medical Handover Report
Medical Handover Report
Prepared by: [Your Name]
Date: October 28, 2050
I. Patient Information
|
Field |
Details |
|---|---|
|
Patient Name |
Barry Morar |
|
Date of Birth |
01/01/1980 |
|
Medical Record Number |
MRN123456 |
|
Admission Date |
10/15/2050 |
|
Discharge Date |
10/28/2050 |
II. Clinical Summary
Patient Condition
Barry Morar was admitted with a diagnosis of acute pneumonia. His initial treatment included intravenous antibiotics and supportive care. The patient's condition stabilized over the course of his stay, with significant improvement noted on 10/25/2050.
Key Interventions
-
Antibiotic Therapy: Administered Ceftriaxone 1g IV every 24 hours.
-
Oxygen Therapy: Maintained at 2L/min via nasal cannula.
-
Fluid Management: IV fluids at a rate of 125 mL/hr.
III. Medications at Discharge
|
Medication |
Dosage |
Route |
Frequency |
Indication |
|---|---|---|---|---|
|
Amoxicillin |
500 mg |
Oral |
Every 8 hours |
Infection prevention |
|
Albuterol |
90 mcg |
Inhalation |
As needed |
Bronchospasm relief |
|
Prednisone |
10 mg |
Oral |
Once daily |
Inflammation reduction |
IV. Follow-Up Plan
Follow-Up Appointments
-
Pulmonology: Schedule an appointment within 2 weeks post-discharge.
-
Primary Care Physician: Visit within 1 month for routine check-up.
Home Care Instructions
-
Monitor temperature daily and report any signs of fever above 100.4°F.
-
Maintain hydration, aiming for at least 2 liters of fluid intake daily.
-
Administer prescribed medications as directed.
V. Contact Information
For further inquiries or clarification, please reach out to [Your Name] at [Your Email] or contact [Your Company Name] at [Your Company Email]. You can also visit us at [Your Company Address] or call us at [Your Company Number].
VI. Additional Notes
-
Family Involvement: Family members have been educated on the discharge plan and medication administration.
-
Patient Understanding: The patient verbalized understanding of the discharge instructions.
