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.

Report Templates @ Template.net