Who uses this form
Hospitalists, residents, and discharging clinicians producing the summary that follows a patient out of the building.
How to use the discharge summary form
A discharge summary is the handover document for everyone who treats the patient next, and it is read by people with no access to the admission. That audience shapes what belongs in it: the receiving primary care physician needs the reasoning and the outstanding items, not a day-by-day chronology.
The medication list is the highest-risk element in the document. Adverse events after discharge cluster around medication discrepancies, so this template asks for the full reconciled list with dose, route, and frequency, and specifically which medications are new or changed. A list that does not distinguish continued from changed drugs pushes that reconciliation onto a community pharmacist working without the admission notes.
Two fields exist because they are the ones most often omitted and most often consequential. Pending results asks what was still outstanding at discharge and who is responsible for chasing it - the single most common way a significant finding is lost. Return precautions asks which symptoms should prompt immediate return, which is the difference between a patient who presents early and one who waits.
Hospital course should be a narrative, not a log. What the patient presented with, what was investigated, what was done, and how they responded. A reader should finish it understanding why the discharge diagnosis differs from the admitting one, if it does.
Condition at discharge is separated from the hospital course because it answers a question the narrative does not: is this patient better, stable, or leaving against advice? Whoever sees them next needs a baseline to measure against, and "discharged home" describes a destination rather than a state.
Diet and activity restrictions are on the form because they are the instructions most often given verbally and then forgotten in the car park. Written down, they are also the instructions a family member can follow when the patient cannot recall them - which, after an inpatient stay, is a substantial proportion of the time.
A practical observation about when this document gets written. Discharge summaries are typically produced last, after the patient has left, from notes and memory - which is why the fields most often thin are the ones most often consequential. Dictating the summary at the point of discharge, while the admission is still in mind, produces a materially better document than writing it retrospectively, and it is the single change that most improves handover quality.
Every field, explained
16 fields. Required fields are marked; the rest are optional.
Admission
- Patient NameTextRequired
- Patient being discharged
- Medical Record NumberText
- Internal record identifier
- Admission DateDateRequired
- Date the patient was admitted
- Discharge DateDateRequired
- Date the patient was discharged
Diagnoses
- Admitting DiagnosisLong textRequired
- Working diagnosis at the time of admission
- Discharge DiagnosisLong textRequired
- Final diagnoses, principal first
- Procedures PerformedLong text
- Operative and diagnostic procedures with dates
Course
- Hospital CourseLong textRequired
- Narrative of the admission: presentation, investigations, treatment, and response
- Condition at DischargeLong textRequired
- Clinical status when the patient left
Discharge Plan
- Discharge MedicationsLong textRequired
- Full reconciled list with dose, route, frequency, and which are new or changed
- Diet and ActivityLong text
- Restrictions and instructions
- Follow-Up AppointmentsLong textRequired
- Who, when, and where, including anything already scheduled
- Return PrecautionsLong textRequired
- Symptoms that should prompt immediate return
- Pending ResultsLong text
- Tests outstanding at discharge and who will follow them up
Attestation
- Discharging ProviderSignatureRequired
- Signature of the clinician authorising discharge
- Date SignedDateRequired
- Date of attestation
What a completed form is used for
- Handover to primary care after an inpatient stay
- Medication reconciliation at the point of discharge
- Documenting outstanding investigations and who owns them
- Giving the patient written instructions and return precautions
- Supporting the coding of an inpatient episode
- Giving a family member written instructions the patient may not recall
- Evidencing that return precautions were communicated at discharge
Discharge Summary questions
What must a discharge summary include?
Admission and discharge diagnoses, procedures performed, a narrative of the hospital course, condition at discharge, the full reconciled medication list marking what is new or changed, follow-up arrangements, return precautions, and any results still pending with a named owner. Requirements also come from your facility’s medical staff rules and from payers, which may add elements.
How quickly does a discharge summary need to be completed?
Facility rules and accreditation standards set the deadline, commonly within a short defined period after discharge, and it is frequently missed because the summary is written last. Dictating it at the point of discharge rather than retrospectively is the practical fix.
Why does the medication list need to flag what changed?
Because whoever receives the patient cannot tell otherwise. A list of twelve medications with no indication of which three are new and which two had doses altered forces a community pharmacist or primary care physician to reconstruct the change set from an old record, and that reconstruction is where errors enter.
Who is the audience for a discharge summary?
Whoever treats the patient next, and they will have no access to the admission record. That shapes what belongs in it: a receiving primary care physician needs the reasoning, the medication changes, and the outstanding items - not a day-by-day chronology of the stay. Write it for a reader who was not there.
Can discharge summaries be dictated and transcribed?
Yes, and it is standard practice. Dictating at the point of discharge captures detail that degrades quickly. Every file should go through human review before it reaches the chart, because dosages and drug names are precisely where unreviewed automated transcription is least reliable.
The regulatory information on this page is general background compiled from public primary sources, not legal or compliance advice. Requirements change and vary by jurisdiction and by court. Verify current rules with the relevant authority or your own counsel before relying on them.