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Hospital Discharge Report

Patient
Name: Renner, Justine
DOB: 26-AUG-1979 (Age: 46)
Gender: female
ID: 5986-489081-5
Author
Etzold, Leander
Hospital Discharge Report
Report Date: 11-DEC-2010
Hospital Admission: --
Hospital Discharge: --

Synthesis

Voluntary surgical sterilization, procedure completed

Hospital course note

Dear colleague, I am writing to inform you regarding your patient, a 46-year-old female, who was admitted to our department on 10.12.2010 for elective voluntary surgical sterilization following her explicit and informed request. Prior to the procedure, a thorough preoperative assessment was conducted, including physical examination, routine laboratory workup, and anaesthetic evaluation, all of which yielded no contraindications. The patient confirmed her decision after comprehensive counselling regarding permanence and alternatives. On 10.12.2010, bilateral tubal ligation was performed laparoscopically under general anaesthesia without intraoperative complications. Postoperative recovery was uneventful. The patient was discharged home on 11.12.2010 in good general condition. No further gynaecological follow-up is required from our side. Please continue routine primary care. Should any concerns arise, do not hesitate to contact our department.

Diagnosis at Discharge

Sterilization admitted 11-Dec-2010 active

    Significant procedures

    General anaesthesia 10-Dec-2010 -