PATIENT SUMMARY

Patient: [Full name, preferred name, pronouns]
Date of birth: [Date]
Address and phone: [Current address and phone, and the new address if moving]
Language and communication: [Preferred language, whether an interpreter is needed, hearing, vision, or speech needs]
Prepared on: [Date]
Prepared by: [Name, role, practice, phone]
Purpose: [Transfer to another facility, new primary care clinician, referral, travel, or the patient's own copy]
Sources: [Clinic record, pharmacy record, specialist letters, hospital summaries, patient or family, with dates]

CONTACTS AND CARE TEAM
Emergency contact: [Name, relationship, phone]
Decision-maker: [Who makes health decisions if the patient can't, and the document that names them, or none named]
Primary care clinician: [Name, practice, phone]
Specialists: [Name, specialty, what they manage, phone]
Other services: [Pharmacy, home care, therapists, community programs, with phone numbers]

ACTIVE PROBLEMS
[For each: the problem, the year diagnosed, its status such as stable, improving, or worsening, the latest key measure, and who manages it]

PAST HISTORY THAT STILL MATTERS
Past conditions and surgeries: [Only those that affect care now, with years]
Hospital stays in the past year: [Dates and reasons, or none]

MEDICATIONS
Current: [Each medicine with strength, dose, and when it's taken, and what it's for]
Recently stopped or changed: [Medicine, date, and why, or none]
Who manages medicines: [Patient, family, pharmacy packs, or nursing staff]
Last checked against: [Pharmacy record, the medicines themselves, or both, with the date]

ALLERGIES AND INTOLERANCES
[Substance, reaction, and year, marked as an allergy or an intolerance, or no known allergies]

IMMUNIZATIONS
[Vaccine and date of the last dose: influenza, COVID-19, pneumococcal, tetanus, shingles, RSV, hepatitis B, or others]

KEY RESULTS
[The latest results that matter for the active problems, with dates and the patient's usual values]
Vital signs and weight: [Latest readings with the date, and the usual or dry weight]

IMPLANTED DEVICES AND AIDS
Implanted devices: [Pacemaker, defibrillator, stent, joint replacement, insulin pump, or none, with the year and who follows it]
Aids that travel with the patient: [Hearing aids, glasses, dentures, walker, or none]

FUNCTIONAL STATUS
Mobility and falls: [Walks alone or with an aid, and falls in the past year]
Daily activities: [Bathing, dressing, eating, toileting, medicines: independent or the help needed]
Cognition: [Usual memory and orientation, with any score and its date]

ADVANCE DIRECTIVES AND GOALS OF CARE
Resuscitation: [Attempt CPR, do not attempt CPR, or not yet discussed, with the date and who decided]
Documents: [Advance directive, power of attorney, or medical orders, with dates and where the originals are]
Goals of care: [What matters most to the patient, in their words]
Treatment limits: [Hospital transfer, intensive care, ventilation, dialysis, or no limits set]

SOCIAL CONTEXT
Living situation: [Home, alone or with others, stairs, or a care facility]
Supports: [Family, caregivers, and services, and how often]
Work and daily life: [Work, school, driving, activities that matter to the patient]
Substance use: [Tobacco, alcohol, cannabis, or other, with amounts]

PENDING ITEMS
Results awaited: [Test, date done, and who will follow up]
Referrals and appointments: [Service and date, or still waiting]
For the next clinician: [What to check first, and when]

Shared with: [Patient, family, receiving clinician or facility, pharmacy, with the date]