Healthcare Clinical Abstract

HEALTHCARE CLINICAL ABSTRACT

Facility / Source

Patient Information

Patient Name:   Date of Birth:   Medical Record No.:

Phone:   Gender: Male   Female   Other   Decline to State

Contact & Insurance

Policy/ID #:   Group #:   Subscriber Name:

Encounter Summary

Admission/Visit Date:   Discharge Date:   Admitting Location:

Medications, Allergies & History

Clinical Course & Discharge

Diagnostics Summary

Authorization / Acknowledgment

I hereby acknowledge that the Clinical Abstract above accurately reflects the summary of care provided to me at the source facility to the best of my knowledge. By signing below I authorize the release and disclosure of this Clinical Abstract to the named recipient(s) for continuity of care and related administrative purposes. I understand that this authorization permits disclosure of protected health information, including diagnoses, treatments, and test results, and that such disclosures may be necessary for care coordination.

This authorization expires on: . I understand I may revoke this authorization in writing at any time, except to the extent that information has already been disclosed in reliance on this authorization. I also understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected under applicable privacy laws.

Attestations

The undersigned attests that the Clinical Abstract is a concise and accurate compilation of the patient’s care episode and is provided in accordance with applicable recordkeeping and privacy standards. The facility prepares this summary from medical records, orders, and clinician documentation; it is not a complete medical record but is intended to support clinical continuity.

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