how to write a discharge summary
a well-written discharge summary helps future teams understand the patient’s hospital course and next steps. here’s a practical, ward-ready format you can follow:
🧾 patient information
- full name:
- civil id:
- mrn / hospital no.:
- ward & bed no.:
🏥 admission details
- date of admission:
- date of discharge:
- discharge diagnosis:
📚 clinical summary
[patient’s name] is a [age]-year-old [nationality] [gender], known to have [chronic conditions] (e.g., t2dm on insulin, with diabetic retinopathy, followed by dr. x).
- home medications: [list if relevant]
- allergies: [clearly document or write “no known drug allergies”]
❗ presenting complaint & admission course
the patient presented with [brief hpi] and was admitted as a case of [admission diagnosis].
initial evaluation:
- consciousness: [gcs or mental status]
- vitals: [bp, hr, rr, temp, spo₂]
- exam: [key physical findings]
- labs/imaging: [notable results]
- initial treatment: [e.g., iv fluids, empiric antibiotics]
🏥 hospital course
summarize key developments, day-to-day progress, and any major events:
active issues & management:
[example: hyperglycemia → insulin sliding scale → stabilized]
diagnostics:
[important labs, cultures, imaging, pathology]
procedures (if any):
[date, procedure, indication, findings, complications]
new diagnoses:
[mention if any were made]
complications:
[e.g., hospital-acquired pneumonia, gi bleed]
specialty input:
[e.g., cardiology reviewed for afib → started apixaban]
📤 condition on discharge
- general state: [e.g., clinically stable, oriented, afebrile]
- vitals: [stable/abnormal]
- exam: [normal or key findings]
- recent labs: [notable values or trends]
note anything important for follow-up teams
(e.g., persistent anemia, resolving infiltrates on cxr, ecg findings)
📋 discharge plan
- discussed with: dr. [senior’s name]
- discharge instructions: [e.g., foot care, oxygen use, medication education]
- discharge medications:
drug name – form – route – dose/frequency – duration e.g., furosemide 40 mg tablet, oral, once daily, for 5 days - follow-up investigations: [e.g., rpt rft in 1 week, ct chest in 6 weeks]
- follow-up appointments: [clinic, date, time, physician]
- referrals / sick leave: [e.g., endocrine opd referral, 2-day sick leave]
📎 attached documents
[✓] discharge prescription
[✓] referral letters
[✓] opd request forms
[✓] sick leave / medical report
🖊️ final notes
- always include date, time, and your signature
- mention the senior doctor involved in the plan
- avoid copy-paste: keep it personalized and relevant
- write clearly: this is for your colleagues (and maybe yourself later)