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Sandy Ho Posted 15 years ago
Medical & Dental Studies

Medical Records

Hi,there

I translated a medical records. Before showed to a doctor, I want your honest opinion.Any sugesstion is appreciated.

Summary for discharge from hospital

Hospitalized Period: July 17th, 2006 to July 31th, 2006

Diagnosis for discharge: Anosteotomy operation for the correction of deformity for both shanks(or lower limbs?) had been
performed.

Condition when hospitalized: To be hospitalized one year ago due to congenital valgus deformities of both feet.
After the osteotomy operation for the correction of deformity for both shanks, expression
and vital sign was instable.

Treatment: To dismantle internal fixation and suture incision.

Condition when discharge: Incision well-healed. Discharged after sutures out.

Medical order: Be careful about food choices (or Watch your diet?)

Thank you in advance

  

Top answer

I would make a few small corrections and remove unneeded words. My new changes are in boldface: Summary for discharge from hospital Hospitali zation Period: July 17 th to July 31 th , 2006 Diagnosis upon discharge: An osteotomy operation for the correction of deformit ies in both lower limbs had been performed. Condition when hospitalized: Previously hospitalized one year ago due to congenital valgus deformities of both feet.

  • I would make a few small corrections and remove unneeded words.
  • My new changes are in boldface: Summary for discharge from hospital Hospitali zation Period: July 17 th to July 31 th , 2006 Diagnosis upon discharge: An osteotomy operation for the correction of deformit ies in both lower limbs had been performed.
  • Condition when hospitalized: Previously hospitalized one year ago due to congenital valgus deformities of both feet.
  • After the osteotomy operation, expression and vital sign s were instable.
  • Treatment: To dismantle internal fixation and remove suture s .
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4 Answers
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I would make a few small corrections and remove unneeded words. My new changes are in boldface:

Summary for discharge from hospital

Hospitalization Period: July 17th to July 31th, 2006

Diagnosis upon discharge: An osteotomy operation for the correction of deformities in both lower limbs had been performed.
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Thanks a million for your correction, Doctor D. This is really a big help.

It seems I got wrong about one sentence,

I change my work to this

Treatment: To dismantle internal fixation and close the incision with sutures.
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That makes better sense. Your wording there is fine.
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Hello Sandy,

I am herewith furnishing the possible subheadings in the discharge summary. Please go through the following subheadings in the

discharg summary.

Possible HEADINGS and SUBHEADINGS for the DISCHARGE SUMMARY
DISCHARGE SUMMARY
ADMITTING DIAGNOSIS:
HI

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