1-17. CONCLUSIONS. When the patient is dispositioned, certain forms must be
prepared for inclusion in the Inpatient Treatment Record. They are the:
should be dictated promptly upon disposition of the patient. It is then transcribed on SF
502 (Narrative Summary). The NS should be concise but must include (in narrative form)
the following information:
(1) The reason for hospitalization, including a brief clinical statement of the chief
complaint and history of the present illness.
(3) All procedures performed and treatment given, including patient's response,
complications, and consultations.
(4) The condition of the patient upon transfer or discharge.
(5) The discharge instructions given to the patient or his family, such as physical
activity permitted, medication, diet, and follow-up care.
(6) All relevant diagnoses made up to the time of discharge or transfer.
b. A discharge note must be entered on SF 509, Doctor's Progress Notes.
c. In an Abbreviated ITR, a discharge note on SF 509 or SF 539 is all that is