Discharge Summary

last authored: Nov 2011, David LaPierre
last reviewed:

 

Introduction

The discharge summary is a critical aspect of documentation and should should provide the reader with details surrounding hospitalization - how and why did the patient come to hospital? What happened while they were admitted? What tests were done, and what did they show? What treatments were provided? What was planned after discharge?

 

The discharge summary serves as a record for the team who will immediately be caring for the patient, as well as for health care providers in the future who may wish to refer to details. It also provides important evidence in the case of legal challenge. It is important to it is completed sufficiently quickly and with sufficient quality (Kripilani et al, 2007). The discharge summary must be well-organized, in order to ensure information is not left out and is easily searchable. We encourage you to use a standardized template, in order to streamline discharge summary creation and reading (Louden, 2009).

 

 

 

Components

Patient demographics

Name, age, account number.

Copies to: referring physician/family physician, as well as any other healthcare provider that is involved in the patient care or that would benefit knowing what happened to the patient while in hospital.

Admission and discharge date.

 

 

Most Responsible Diagnosis

Based on the chief complaint, with a brief attending history, physical exam, and investigations leading to diagnosis.

 

 

Post-Admit Comorbidities

These are conditions that affected impacted hospitalization, and should include complications and infections.

 

 

Pre-Admit Comorbidities

Conditions that were present prior to admission and that contributed to length of stay.

 

 

Secondary Diagnoses

Conditions that were present prior to admission and that did NOT contribute to length of stay.

 

 

Procedures and Interventions

These are to allow future care providers to understand what was done, and should include surgeries and lines. This will facilitate monitoring during followup.

 

 

Course in Hospital

Include relevant signs and symptoms, investigations, and treatments related to the above diagnoses.

 

 

Medications at discharge

It can be helpful to make bold new medications.

 

 

Condition at Discharge

It can be helpful to begin this section with "In summary" in order to prime readers who are scanning the page. Include active problem list and vitals, relevant signs and symptoms.

 

 

Disposition

Provide clear explanations of next steps, including:

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Examples (Fictitious Cases)

  • adult pneumonia
  • pediatric diarrhea
  • Caesarean section

Adult Pneumonia

 

 

Patient demographics

John Sampson, DOB Oct 17, 1952

hospital number 12345678

Date of admission: Nov 13, 2011

Date of discharge: Nov 15, 2011

 

 

Most Responsible Diagnosis

right middle lobe pneumonia

 

Post-Admit Comorbidities

none

 

Pre-Admit Comorbidities

diabetes mellitus

smoking

 

Secondary Diagnoses

osteoarthritis

 

Procedures and Interventions

IV access obtained

 

Course in Hospital

Mr Sampson was admitted with a 3 day history of worsening cough, shortness of breath, chest pain, and fever. At admission, his pulse was 126 and oxygen saturation was 88%. White blood cell count was 18. ECG and troponin were normal. Chest X-ray revealed R middle lobe pneumonia, and IV ceftriaxone was started. Blood cultures revealed Streptococcus penumoniae. Mr Sampson responded rapidly to antibiotic therapy, and oxygen requirements decreased after one day. He remained afebrile and his white blood cell count normalized on Nov 14. He was switched to oral antibiotics successfully and discharged home on Nov 15.

 

Medications at discharge

metformin 500mg BID

rampiril 5mg daily

cefuroxime 500mg BID x 5 days (new medication)

 

Condition at Discharge

As described, Mr Sampson's vitals and WBC count normalized at time of discharge. His cough persisted, but was much less productive. His shortness of breath and chest pain had resolved.

 

Disposition

Mr Sampson was discharged home with his wife. He is fully independent. He is to follow up with his family physician in 7-10 days to ensure clinical resolution and to discuss smoking cessation. Chest X-ray is to be done after one month to assess lungs, including for malignancy.

Mr Sampson was advised to return to hospital if his symptoms return.

 

 

 

 

Additional Resources

Kripalani S et al. 2007. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 297(8):831-41.

Louden K. 2009. Creating a better discharge summary. ACP Hospitalist.

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