Discharge Summary 📝
Guide for writing discharge summaries. Template, structure, medication reconciliation, and documentation requirements for NCHDs.
🧠 Purpose
- A discharge summary communicates a patient’s hospital stay to their GP or next care provider.
- It should be clear, concise, and structured — covering diagnosis, treatment, progress, follow-up, and medication changes.
📋 Structure
- Patient Details — Name, DOB, MRN, Consultant, Admission/Discharge Dates.
- Diagnosis — Primary diagnosis first, then relevant secondary diagnoses.
- Reason for Admission — One or two lines summarising why they presented.
- Hospital Course — What was done, complications, progress made.
- Investigations — Key bloods, imaging, pathology with any abnormal results and actions.
- Procedures — Name, indication, date, and outcome of any significant procedures.
- Medications — List on discharge, highlighting new/changed/stopped drugs.
- Follow-Up — Include specialty clinics, GP tasks, community referrals.
- Allergies — Clearly noted.
🛠 Tips
- Be chronological when possible but focus on relevance.
- Avoid unnecessary medical jargon — summaries are for GPs and patients too.
- Use bullet points or headings if the EMR allows.
- Spell out acronyms at least once.
- Copy-paste wisely — ensure accuracy and update info.
📬 Common GP Tasks to Include
- Wound care/dressing changes
- Monitoring bloods (e.g. U&Es, Hb)
- Medication titration or review
- Arranging outpatient imaging
- Chronic disease follow-up (e.g. diabetes, COPD)
⚠️ Pitfalls to Avoid
- Omitting key diagnoses or events
- Failing to update the medication list
- Vague follow-up instructions (“Follow-up as needed”)
- Poor grammar/spelling or leaving placeholders (“TBC”)
Note Template
Ready-to-use clinical note structure
🕒 26 / 05 / 2026 — 17:11 Discharge Summary Patient: [age] [sex] Admission Dx: [reason for admission] + [additional diagnoses] PMHx: [relevant comorbidities / secondary diagnoses] 🧾 Hx: • Admission details, including method (elective/emergency/BIBA) and reason • Course in hospital, consultant in charge, and any complications • Procedures and investigations performed 🩺 Exam: • Status at discharge • Relevant clinical findings 📋 Impression: Summary of diagnoses and clinical course 📌 Plan: • Medications on discharge • Follow-up appointments and referrals • Patient education and warning signs • Community support and services 👤 [Your Name], [Role] IMC: _______