The admission and the discharge summary
From the board, or from Admissions on the patient record.
The patient sits at the top with the operation, the room, the consultant and the dates; below that the page is four sections you open one at a time, so you can see what is on it without scrolling: Ward record, Attachments, Discharge summary and Changes. Each shows its tally shut, and the one you last had open is the one that opens next time.
An admission is dated ward entries in sections, each locked at the end of the day it was written, with a note of who changed what and when. New entry sits at the top of the Ward record, above the entries it joins. Admission, planned discharge and discharge are recorded as entries. Record arrival takes the day and time the patient actually came in, so it can be written up afterwards, and never a day in the future. Paper documents are filed on the admission by their name.
The discharge summary is a section on the admission with its headings to write, and its tally says how many are written before you open it; it is the section open on arrival once the patient is discharged. Print the discharge summary prints it. Changes lists every change made on the page with who made it.
The first time an admission with an empty discharge summary is opened, the summary fills with the hospital's usual wording for each heading, and with the operation's own wording where somebody has set it for that operation. It is ordinary text: change it in place. A summary that already has anything written in it is never filled, and neither is one discharged before the hospital had any defaults.
Default beside a heading makes that heading's text, as it stands, the starting point for summaries filled from then on. It asks first: This organisation changes it for the whole hospital, This operation only for this operation and no other, and Cancel changes nothing. Pressing it on an empty heading removes that default. Writing in a patient's summary never changes a default, and changing a default never changes a summary already written. Changes to the defaults, beside Print, lists every change with who made it, when, the text it replaced, and Put back.
An admission marked discharged without a date, which happens when the discharge was ticked on the old screen, offers Record the discharge date so the ward record carries it.