Discharge Summary 📝

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🧠 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

🕒 20 / 11 / 2025 — 22:37

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: _______
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