12 KiB
Discharge Summary Template
Patient Information
Patient Name: [Last, First]
Medical Record Number: [MRN]
Date of Birth: [MM/DD/YYYY]
Age: [years]
Sex: [M/F]
Admission Date: [MM/DD/YYYY]
Discharge Date: [MM/DD/YYYY]
Length of Stay: [X days]
Admitting Service: [Medicine/Surgery/Cardiology/etc.]
Attending Physician: [Name]
Primary Care Physician: [Name and contact]
Consulting Services: [List specialties that saw patient]
Admission Diagnosis
[Primary reason for hospitalization]
Example: "Acute decompensated heart failure"
Discharge Diagnoses
[Numbered list, prioritized by clinical significance]
Primary Diagnosis:
- [Primary diagnosis with ICD-10 code]
Secondary Diagnoses: 2. [Secondary diagnosis with ICD-10 code] 3. [Additional diagnosis with ICD-10 code] 4. [Comorbidity with ICD-10 code]
Example:
1. Acute decompensated heart failure (I50.23)
2. Acute kidney injury on chronic kidney disease stage 3 (N17.9, N18.3)
3. Hypokalemia (E87.6)
4. Type 2 diabetes mellitus (E11.9)
5. Coronary artery disease (I25.10)
Hospital Course
[Comprehensive yet concise narrative of hospital stay - can be organized chronologically or by problem]
Chronological Format:
[Date Range or Hospital Day 1-X]:
[Patient Name] was admitted to the [service] service with [chief complaint/presenting problem]. On presentation, patient was [clinical status]. Initial workup revealed [key findings].
[Description of key events, interventions, and response to treatment organized by day or by problem]
Hospital Day 1: [Events and interventions]
Hospital Day 2-3: [Progression, response to treatment]
Hospital Day 4-7: [Continued treatment, consultations, procedures]
Final Hospital Days: [Stabilization, preparation for discharge]
Problem-Based Format (Alternative):
1. [Primary Problem]
- Presentation and initial management
- Diagnostic workup
- Treatment course
- Response and outcome
- Status at discharge
2. [Secondary Problem]
- [Similar structure]
3. [Additional Problems]
Key Events and Interventions
Consultations Obtained:
- [Specialty] consulted on [date] for [reason]: [Recommendations]
Procedures Performed:
- [Procedure name] on [date]: [Indication, findings, complications if any]
Significant Diagnostic Studies:
- [Test/imaging] on [date]: [Key findings relevant to discharge care]
Complications:
- [Any complications that occurred]: [How managed]
Procedures Performed During Hospitalization
-
[Procedure name] ([Date])
- Indication: [Why performed]
- Findings: [Key findings]
- Complications: [None / specific complications]
-
[Additional procedures]
Hospital Course Summary (Brief Version)
[One paragraph summary suitable for quick reference]
Example:
Mr. [Name] was admitted with acute decompensated heart failure in the setting of
medication non-adherence. He was diuresed with IV furosemide with net negative
5 liters over 3 days, with significant improvement in dyspnea and resolution of
lower extremity edema. Echocardiogram showed EF 30%, similar to prior. Kidney
function improved to baseline with diuresis. He was transitioned to oral diuretics
on hospital day 3 and remained stable. Patient was ambulating without dyspnea on
room air by discharge. Comprehensive heart failure education was provided.
Discharge Physical Examination
Vital Signs:
- Temperature: _____ °F
- Blood Pressure: _____/_____ mmHg
- Heart Rate: _____ bpm
- Respiratory Rate: _____ breaths/min
- Oxygen Saturation: _____% on [room air / O2]
- Weight: _____ kg (Admission weight: _____ kg)
General: [Appearance, distress level]
Cardiovascular: [Heart sounds, edema]
Pulmonary: [Breath sounds, work of breathing]
Abdomen: [Tenderness, bowel sounds, distention]
Extremities: [Edema, pulses]
Neurological: [Mental status, focal deficits]
Wounds/Incisions (if applicable): [Healing status]
Pertinent Laboratory and Imaging Results
Discharge Labs ([Date])
| Test | Result | Reference Range |
|---|---|---|
| WBC | [Value] | [Range] |
| Hemoglobin | [Value] | [Range] |
| Platelets | [Value] | [Range] |
| Sodium | [Value] | [Range] |
| Potassium | [Value] | [Range] |
| Creatinine | [Value] | [Range] |
| [Other relevant labs] | [Value] | [Range] |
Imaging/Diagnostic Studies
[Study name] ([Date]): [Key findings relevant to outpatient management]
Discharge Medications
[Complete list with clear indication of changes from admission]
New Medications (Started During Hospitalization)
- [Medication name] [dose] [route] [frequency]
- Indication: [Why prescribed]
- Duration: [If limited duration]
- Special instructions: [With food, time of day, etc.]
Changed Medications (Dose or Frequency Modified)
- [Medication name] [NEW dose] [route] [frequency]
- CHANGED FROM: [Previous dose and frequency]
- Reason for change: [Why modified]
Continued Medications (No change from home medications)
- [Medication name] [dose] [route] [frequency]
- CONTINUED from home regimen
Discontinued Medications (Stopped During Hospitalization)
- [Medication name] - DISCONTINUED
- Reason: [Why stopped]
Complete Medication List for Patient
[Consolidated list in simple format for patient]
1. Furosemide 40 mg by mouth once daily [NEW - for fluid management]
2. Carvedilol 12.5 mg by mouth twice daily [CONTINUED]
3. Lisinopril 20 mg by mouth once daily [CONTINUED]
4. Metformin 1000 mg by mouth twice daily [CONTINUED]
5. Aspirin 81 mg by mouth once daily [CONTINUED]
Discharge Condition
Overall Status: [Stable / Improved / Baseline / Requires continued care]
Specific Assessments:
- Hemodynamic status: [Stable]
- Respiratory status: [Room air / Oxygen requirement]
- Mental status: [Alert and oriented x3 / Other]
- Functional status: [Ambulatory / Requires assistance / Bedbound]
- Pain control: [Adequate / Inadequate]
- Wound healing (if applicable): [Appropriate / Delayed]
Example:
Patient is hemodynamically stable, ambulatory without assistance, no supplemental
oxygen requirement, euvolemic on physical exam, pain well-controlled, and has
returned to baseline functional status.
Discharge Disposition
[Where patient is going after hospital discharge]
Options:
- Home with self-care
- Home with home health services
- Skilled nursing facility
- Acute rehabilitation facility
- Long-term acute care hospital
- Hospice (home or facility)
- Left against medical advice (AMA)
- Transferred to another acute care facility
Discharge Disposition: [Selection from above]
Services Arranged:
- Home health nursing
- Physical therapy
- Occupational therapy
- Durable medical equipment: [List items]
- Home oxygen: [Flow rate and delivery method]
- Other: [Specify]
Follow-Up Appointments
-
[Specialty/PCP] with Dr. [Name]
- Date/Time: [Scheduled date and time] OR [Within X days/weeks]
- Location: [Clinic name and address]
- Phone: [Contact number]
- Purpose: [What needs to be addressed]
-
[Additional appointments]
Pending Studies/Labs at Discharge
- [Test name]: [When due, where to go, reason]
- Results will be sent to: [Provider name]
Referrals Placed
- [Specialty]: [Reason for referral, contact information]
Patient Instructions
Activity
- [Specific activity restrictions or recommendations]
- Example: "Resume normal activities as tolerated. Avoid heavy lifting >10 lbs for 2 weeks."
Diet
- [Dietary restrictions or recommendations]
- Example: "Low sodium diet (less than 2 grams per day). Fluid restriction to 2 liters per day."
Wound Care (if applicable)
- [Incision care instructions]
- [Dressing change frequency]
- [When stitches/staples should be removed]
Self-Monitoring
- [What patient should monitor at home]
- Example: "Weigh yourself every morning. Call doctor if weight gain >2 lbs in 1 day or >5 lbs in 1 week."
Equipment/Supplies
- [Equipment provided or prescribed]
- [How to use]
Medications
- [General medication instructions]
- [Importance of compliance]
- [What to do if dose missed]
Return Precautions / Warning Signs
Call your doctor or return to emergency department if you experience:
- [Specific warning signs relevant to condition]
- [When to seek immediate care vs. call doctor]
Example for heart failure:
- Worsening shortness of breath or difficulty breathing
- Chest pain or pressure
- Severe swelling in legs or abdomen
- Weight gain more than 2 lbs in one day or 5 lbs in one week
- Dizziness, lightheadedness, or fainting
- Fever >101°F
- Any other concerning symptoms
Emergency Contact Numbers:
- Primary care physician: [Phone]
- Specialty clinic: [Phone]
- After-hours nurse line: [Phone]
- 911 for emergencies
Patient Education Provided
Topics discussed with patient and/or family:
- Disease process and prognosis
- Medication purpose, dosing, and side effects
- Warning signs and when to seek care
- Activity and dietary restrictions
- Follow-up appointments
- Use of medical equipment
- [Other specific topics]
Patient/Family Understanding: [Patient and family verbalize understanding of discharge instructions / Teach-back method used and patient able to repeat key points / Interpreter used]
Written Materials Provided:
- Discharge instructions
- Medication list
- Disease-specific education materials
- Emergency contact information
- Appointment information
Code Status at Discharge
Code Status: [Full code / DNR / DNI / Other limitations]
[If changed during hospitalization, note when and why]
Additional Information
Advance Directives
- Advance directive on file
- Healthcare proxy designated: [Name and contact]
- Living will present
Social Situation
[Relevant social factors affecting discharge plan]
- Living situation: [Lives alone / with family / assisted living]
- Caregiver support: [Available / Limited / None]
- Transportation: [Adequate / Needs assistance]
- Barriers to compliance: [Financial / Cognitive / Language / Other]
Pending Issues at Discharge
[Tests or consultations still pending that require outpatient follow-up]
Signature
Prepared by:
[Physician name, credentials]
[Pager/Contact number]
Cosigned by (if resident/fellow):
[Attending physician name]
Date and Time: [MM/DD/YYYY at HH:MM]
Electronically signed: [Yes/No]
Template Completion Checklist
- All discharge diagnoses listed with ICD-10 codes
- Hospital course summarized clearly
- All procedures documented
- Discharge medications reconciled and clearly marked (new/changed/continued/stopped)
- Follow-up appointments scheduled or timeframe provided
- Patient education documented
- Return precautions specific to patient's conditions
- Pending tests/results documented with follow-up plan
- Code status documented
- Completed within 24-48 hours of discharge (institutional requirement)
- Sent to primary care physician and relevant specialists
- Copy provided to patient
Notes
Timing Requirements:
- CMS requires completion within 30 days
- Many hospitals require 24-48 hours
- Should be available for follow-up appointments
Distribution:
- Send to primary care physician
- Send to referring physician
- Send to consulting specialists involved in care
- Provide copy to patient
- Upload to shared HIE (Health Information Exchange)
Quality Measures:
- Medication reconciliation required
- Clear communication of changes
- Specific follow-up plans
- Patient education documented