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A discharge summary is a clinical report prepared by medical or mental health practitioners when a patient is ready for discharge from a hospital. The discharge summary informs outpatient medical or mental health workers about services provided by the inpatient facility, including the complaint on admission, diagnoses, medications, treatments, and recommendations for outpatient follow-up services. The discharge summary should include all information pertinent to the on-going treatment of the patient and the patient's condition.
Provide date of admission and the diagnosis. The admission diagnosis provides information regarding the presenting problem and reasons for hospitalisation. The diagnosis is a clinical term describing the problem. Avoid lengthy descriptions. Code for the problem, not the symptoms of the problem.
Write a summary of the history of the presenting condition. Write a summary of any past treatments provided to the patient for the current complaint by reviewing the patient's records, including the patient's self-reported history.
List test results and findings. State procedures performed, including dates and results.
Write a brief summary of the hospital course. Do not include routine tests and procedures, fluid monitoring, blood pressure monitoring and minor medication adjustments. Include treatments pertinent to the diagnosis, along with information regarding any complications. A few sentences are usually sufficient to record the summary of the hospital course.
Include final and secondary diagnoses. The final diagnosis refers to the presenting condition and the status of the condition after hospital treatment. The secondary diagnosis refers to on-going conditions that were not the subject of the current hospitalisation.
State the disposition. The disposition refers to where the patient is going after discharge. The disposition may be, for example, the patient's home, the home of another person, a nursing home or rehabilitation facility.
Describe the condition of the patient at the time of discharge. Patients should be stable. Include admission and discharge weight.
State recommendations for the patient's continued care. Include detailed instructions regarding diet, wound care when applicable, symptoms requiring medical attention and outpatient appointments. Provide clear and specific details. Anticipate questions the patient or the patient's carers may have regarding the patient's care.
List discharge medications. Include dosage and instructions regarding frequency and time of day the medication should be taken.
Date the discharge summary and provide the name of the person who prepared the report.
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