Past Hospitalization Record Form

The Past Hospitalization Record Form provides a structured method for documenting every significant hospital encounter in a patient's medical history. Each hospitalization entry captures the admitting facility, admission and discharge dates, admitting and discharge diagnoses, attending physician, procedures and surgeries performed during the stay, ICU admission status, length of stay, and discharge disposition (home, skilled nursing facility, rehabilitation, against medical advice). This level of detail is critical for providers who need to understand the severity and trajectory of a patient's past medical events.

Emergency department visits are documented separately from inpatient admissions, capturing presenting complaint, diagnostic workup performed, treatment administered, and disposition. The form distinguishes between ED visits that resulted in admission and those that resulted in discharge, as this pattern provides valuable insight into disease acuity and healthcare utilization. Observation stays and short-stay admissions are also captured with appropriate classification.

The template includes a post-discharge complication section for each admission, documenting readmissions within 30 days, post-surgical complications, healthcare-associated infections, and medication reconciliation issues that arose during transitions of care. This information is invaluable for risk stratification, care coordination, and identifying patients who may benefit from enhanced transitional care management. The form is used by primary care practices, hospitalist services, care coordination programs, and any provider establishing care with a patient who has a significant hospitalization history.