How to Write a Discharge Summary

The purpose of the discharge summary is to provide a concise and comprehensive summary of the patient's hospital stay to their primary care provider and other healthcare professionals involved in their ongoing care.

A discharge summary is a medical document that summarizes a patient's hospital stay and treatment plan after they have been discharged from the hospital

The discharge summary typically includes a brief summary of the reason for hospitalization, any significant medical history, findings from the physical examination, diagnostic tests, procedures performed, and the treatment plan.

The discharge summary also includes a list of medications the patient was taking at the time of discharge and any new medications prescribed, as well as any follow-up instructions, such as recommendations for follow-up appointments or referrals to specialists.

Discharge summaries can vary in format and content between different healthcare institutions.

Each institution may have their own preferred way of formatting and organizing information, as well as their own set of required information to include in the discharge summary.

Here we include a template of general elements that are typically included in most discharge summaries.

Discharge Summary Template

Patient Demographics:

• Patient Name: First and Last Name, and preferred name(s).

• Patient Identifier: Can include hospital medical record number and/or Health card number.

• Patient Age: Date of birth and age

• Patient Gender

• Substitute Decision Makers: Names, relations and contact information of any SDMs.

• Code Status: Full Code, Limited Code Do not resuscitate (DNR), Palliative care

Hospital Encounter Information:

• Date of Admission: [date]

• Date of Discharge: [date]

• Length of Stay: [number of days]

• Discharge Diagnosis: The diagnosis made at the patient’s course in hospital. If there is more than one you can usually select the most responsible diagnosis for the patient’s stay.

  • Surgery: If the reason patient’s stay was to undergo surgery, - you can include the name of the surgical procedure here instead of “Discharge Diagnosis”

  • MRP/Surgeon: If surgery was done, include name of the surgeon. If not, include the most responsible provider (MRP).

• Discharge Disposition: The location the patient will go to after discharge from the hospital (e.g. home, long-term-care, complex continuing care, rehab, or death)

Diagnosis:

• Past Medical History: include conditions that patient had prior to be admitting hospital, co-morbidities, past hospitalizations, complications following procedures.

• Conditions Developed During Hospital: Include conditions that developed that impacted patient’s length of stay

• Allergies: Include any drug, environmental or drug allergies including reactions (e.g. Anaphylaxis, hives). You may also include medication side effects as necessary (e.g. GI intolerance).

Course while in Hospital:

• Reason for Hospitalization: Include diagnosis/reason for hospitalization. add a brief history of the presenting illness.

• Summary of Hospital Course:
  Include a description of the patient’s hospital stay, including allied health seen, any complications or adverse events that arose.

• Investigations: Include results of relevant diagnostic tests pertaining to patient’s hospital stay, including labs, imaging studies, biopsies. This should be succint summaries.

• Interventions (Procedures and Treatment): Include procedures or treatments that took place during the patient’s hospital stay

Discharge Plan:

• Medications: Include home medications to be continued, which medications were changed and new medications on discharge.

• Patient Instructions for Patient:

  • Patient Education: Include specific patient education instructions, including instructions for medications and any lifestyle modifications, wound-care, went to present back to the hospital.

  • Contact Information: Include contact information of the health care team, and instructions for the patient and family to contact the hosptial or health care team if needed.

• Follow-Up Plan for Receiving Providers:
  Included information on referrals to specialists or instructions for follow-up with patient’s primary care provider.

• Copies sent to: Include other clinicians who are included in care of the patient.