Structure d'un compte rendu d'hospitalisation

A hospital discharge summary follows a standard structure. It begins with patient details (name, age, sex) and the chief complaint (CC). Then comes the history of present illness (HPI), past medical history (PMH), physical examination, and investigations. After that, you describe the treatment given and the discharge plan. This logical order helps any reader understand the patient's stay quickly.

📖 Définition

A discharge summary is a document written when a patient leaves the hospital, summarizing the stay.

📢 Rappel

You already know basic medical terms like 'patient', 'doctor', 'nurse'; now we add hospital-specific vocabulary.

⭐ À retenir

Always follow the chronological order: admission → investigations → treatment → discharge.

💡 À retenir : A discharge summary follows a logical order: from admission to discharge.

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Termes et expressions utiles

Vocabulaire médical clé

Use precise medical verbs and nouns. Common verbs include 'to present with', 'to be admitted for', 'to undergo', 'to be prescribed', and 'to be discharged on'. For symptoms, say 'The patient complained of...' or 'reported...'. For diagnoses, use 'was found to have...' or 'was diagnosed with...'. Always name medications and dosages clearly.

📖 Définition

HPI (History of Present Illness) describes the current problem from onset to admission.

🔍 Exemple

'The patient presented with a three-day history of fever and cough.'

⭐ À retenir

Avoid translating French idioms word for word; use standard English medical phrases.

💡 À retenir : Use precise verbs: 'presented with', 'underwent', 'was prescribed'.

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Past tenses, passive voice, linkers

Grammaire et style

Medical reports use the simple past for events that happened during the hospital stay. The passive voice is preferred because the focus is on the patient, not the staff. Use linking words like 'initially', 'subsequently', 'therefore', and 'however' to show sequence and contrast. Keep sentences short and avoid unnecessary adjectives. For example: 'The patient was given oxygen. Subsequently, his saturation improved.'

📢 Rappel

Use the simple past for completed actions: 'He was admitted yesterday.'

⭐ À retenir

Passive voice is common: 'The patient was given antibiotics', not 'We gave the patient antibiotics'.

🔍 Exemple

'Initially, the patient improved; however, he developed a rash.'

💡 À retenir : Prefer passive voice in medical reports: 'The patient was given...'.

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Exemple complet et erreurs à éviter

Rédaction pas à pas

Let's write a short discharge summary together. Start with patient details and reason for admission. Then describe the main investigations and treatment. End with the discharge plan, including medications and follow-up. Example: 'Mr Brown, 67, was admitted for chest pain. He underwent an ECG and blood tests. He was diagnosed with angina and discharged on aspirin. Follow-up in cardiology in two weeks.'

🔍 Exemple

'Mr Smith, 58, was admitted on 2 May for pneumonia. He was treated with IV antibiotics and discharged on oral amoxicillin.'