Medical Summary

A basic medical summary is a history of medical information that includes the following:

• Basic demographics and contact information
  • Patient and family, with guardianship identified, if applicable
  • Contact information for patient and family, including cell phone numbers and e-mail addresses
  • Medical home
  • Emergency contacts
• Key medical, surgical, and injury history
• Current medications, including medication reconciliation
• Allergies
• Immunization record
• Insurance information
• Special instructions
• Pharmacy information

 Patients with chronic conditions benefit from an expanded medical summary that includes the following:

• Basic demographics and contact information
  • Patient and family, with guardianship identified, if applicable
  • Medical home, including primary care provider and care coordinator
  • Emergency contacts
  • Specialists
  • Therapists
  • Home health agency
  • School attended and school contacts
  • Pharmacy information
  • DME supplier information
• Chronic condition(s)
  • Secondary diagnoses
  • Complications
• Key medical, surgical, and injury history
  • Presence of surgically implanted devices or prostheses
  • Important hospitalizations
  • Key laboratory data and imaging results
• Medications
  • Current medications, including medication reconciliation
  • Past medications and reactions
  • Medication precautions, including medications needed during procedures (eg, subacute bacterial endocarditis prophylaxis) and those to be avoided
• Special diets and dietary restrictions
• Allergies
• Immunization record
• Insurance information
• Special instructions, including input from family/patient regarding personal qualities, strengths, preferences