Discharge Summary Template
Create comprehensive discharge summaries that ensure safe transitions of care. Let AI help you document everything patients and their providers need to know.
What is a Discharge Summary?
A discharge summary is a clinical document that summarizes a patient's hospital stay, including the reason for admission, treatments provided, hospital course, and instructions for post-discharge care. It's a critical component of the transition of care process.
Well-written discharge summaries reduce readmission rates, prevent medication errors, and ensure continuity of care between hospital and outpatient providers.
Why Discharge Summaries Matter
Reduce Readmissions
Clear discharge instructions help prevent 30-day hospital readmissions.
Patient Safety
Accurate medication reconciliation prevents dangerous drug interactions.
Care Continuity
Ensures outpatient providers have complete information for ongoing care.
Discharge Summary Components
Patient Information
Basic demographic and admission details
Key elements:
- Patient name and identifiers
- Admission date
- Discharge date
- Length of stay
- Attending physician
- Primary diagnosis
Example:
Patient: John Smith, DOB 03/15/1955, MRN 12345678 Admission Date: 12/10/2024 Discharge Date: 12/15/2024 Length of Stay: 5 days Attending Physician: Dr. Sarah Johnson, MD Primary Diagnosis: Acute exacerbation of COPD (J44.1)
Hospital Course
Summary of what happened during the stay
Key elements:
- Reason for admission
- Key events during stay
- Procedures performed
- Consultations
- Response to treatment
- Complications (if any)
Example:
The patient was admitted with acute shortness of breath and productive cough for 3 days. Initial workup revealed acute exacerbation of COPD with possible superimposed bacterial infection. Chest X-ray showed hyperinflation without infiltrate. Patient was started on systemic corticosteroids (Prednisone 40mg daily), nebulizer treatments (albuterol/ipratropium Q4H), and empiric antibiotics (Azithromycin 500mg day 1, then 250mg days 2-5). Pulmonology consulted on day 2, recommended continuing current therapy. Respiratory status improved significantly by day 3. Patient weaned from supplemental oxygen by day 4. Ambulating well on room air at discharge.
Discharge Diagnoses
Final diagnosis list with ICD-10 codes
Key elements:
- Primary diagnosis
- Secondary diagnoses
- ICD-10 codes
- Resolved conditions
Example:
1. Acute exacerbation of COPD (J44.1) - Primary 2. Community-acquired pneumonia (J18.9) - Resolved 3. Type 2 diabetes mellitus, controlled (E11.9) 4. Essential hypertension (I10) 5. Chronic kidney disease, stage 3 (N18.3)
Discharge Medications
Complete medication list with changes
Key elements:
- New medications
- Changed medications
- Continued medications
- Discontinued medications
- Dosing instructions
Example:
NEW: - Prednisone 40mg PO daily x 5 more days, then 20mg x 3 days, then stop - Azithromycin 250mg PO daily x 2 more days (complete 5-day course) CONTINUE: - Tiotropium 18mcg INH daily - Albuterol MDI 2 puffs Q4-6H PRN shortness of breath - Metformin 1000mg PO BID with meals - Lisinopril 20mg PO daily DISCONTINUED: - Prednisone 5mg daily (replaced with taper above)
Follow-Up & Instructions
Post-discharge care plan
Key elements:
- Follow-up appointments
- Activity restrictions
- Diet recommendations
- Warning signs
- Emergency instructions
Example:
FOLLOW-UP APPOINTMENTS: - Primary Care (Dr. Williams): 1 week, call to schedule - Pulmonology (Dr. Chen): 2 weeks, appointment scheduled 12/29/2024 at 2:00 PM ACTIVITY: Light activity as tolerated. May resume normal activities gradually. DIET: Regular diet. Continue diabetic diet restrictions. RETURN TO ED IF: - Increased shortness of breath or wheezing not relieved by rescue inhaler - Fever > 101°F - Chest pain - Confusion or altered mental status - Coughing up blood
Generate Discharge Summaries in Seconds
PatientNotes AI captures your discharge conversation and generates a complete, comprehensive discharge summary. Ensure nothing is missed while saving hours of documentation time.
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Discharge Summary Best Practices
Complete Medication Reconciliation
Clearly indicate which medications are new, changed, continued, or discontinued. Include dosing and duration.
Clear Follow-Up Instructions
Specify exact appointment dates, times, and providers. Include contact information and what to do if symptoms worsen.
Summarize Key Events
The hospital course should tell a story—why they came in, what happened, and how they improved.
Use Patient-Friendly Language
The patient copy should be understandable. Avoid excessive jargon in instructions they need to follow.
Include Pending Results
Document any labs, imaging, or pathology results that are pending at discharge and who will follow up.
Timely Completion
Complete discharge summaries within 24-48 hours to ensure information is available to outpatient providers.