Documentation · Discharge
Discharge summary
Patient
Header
- Full name
- Civil ID
- MRN / hospital no.
- Ward & bed no.
Admission
- Date of admission:
- Date of discharge:
- Discharge diagnosis:
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]
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
- 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.
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)
- Reconcile against the admission list: continued · stopped · new · changed, each with the reason
- Follow-up investigations: what · when · who reviews the result
- Follow-up appointments: [clinic, date, time, physician]
- Referrals / sick leave: [e.g., endocrine OPD referral, 2-day sick leave]
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
Last clinically reviewed · June 2026 · Last updated · October 2026
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