Discharge summaries
Discharge summary is an essential clinical report generated by physicians or health professionals at the conclusion of a hospital stay. It has the purpose of capturing the patient’s personal information and medical histories, keeping track of treatments and medications during hospitalization as well as recording diagnosis, conclusions and recommendations.
Traditionally, the hospital discharge summaries are created manually or in a free-text format, either paper-based or processor-based (e.g. Microsoft Word)
The discharge summaries are created using a document-based template and are divided into four sections, namely:
- Epilepsy Classification: Describes the etiology, seizure semiology, epileptogenic zone, and co-morbidities of the patient.
- History and Exam: This section describes the seizure types, evolution and frequency of seizure, risk factors and family history, medications, results of physical and neurological examination, and psychosocial history of the patient.
- Evaluation: Results of EEG, Magnetic Resonance Imaging (MRI), and sleep study of the patient are described in this section.
- Conclusions and Recommendations: The recommendation of the attending physician is recorded in this section.
The four sections have interleaving unstructured free text and [[semi-structured “attribute-value” text. The final version of the report is stored as either a PDF document or an image file.
