A discharge summary is a clinical report prepared by medical or mental health practitioners when a patient is ready for discharge from a hospital or care facility. The discharge summary informs outpatient medical or mental health workers about services provided by the inpatient facility: admitting complaint, diagnoses, medications, treatments, and recommendations for outpatient follow-up services. The discharge summary should include all information pertinent to the ongoing treatment of the patient and the patient's condition.
Provide date of admission and admitting diagnosis. The admitting diagnosis provides information regarding the presenting problem and reason for hospitalization. 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 ongoing conditions that were not the subject of the current hospitalization.
State the disposition. The disposition refers to where the patient is going upon 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. Patient should be stable. Include admitting and discharge weight.
State recommendations for 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 caregivers 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.