Discharge summary

Documentation · Discharge

Discharge summary

A ward-ready format for writing discharge summaries that help future teams understand the patient’s hospital course and next steps.

Patient information

Header

  • 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 & initial evaluation

The patient presented with [brief HPI] and was admitted as a case of [admission diagnosis].

  • 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 AF → 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., repeat 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)

Last reviewed · May 2026

MOC