How to Write a Discharge Summary

A discharge summary is a crucial medico-legal document summarizing a patient's hospital stay.

Structure of a Discharge Summary

1. Patient Demographics

• Name, age, gender
• Hospital number
• Admission and discharge dates
• Admitting and discharging consultant

2. Admission Details

• Date and time of admission
• Source of admission (Emergency, OPD, transfer)
• Reason for admission / presenting complaint

3. Diagnosis

• Primary diagnosis
• Secondary diagnoses
• Complications, if any

4. Summary of Hospital Course

• Brief history of presenting illness
• Significant physical findings
• Relevant investigation results
• Medical or surgical interventions performed
• Progress during hospital stay

5. Discharge Status

• Condition at discharge (Improved, stable, referred, etc.)
• Vital signs at discharge

6. Discharge Medications

• List all medications with: name, dose, frequency, duration
• New medications started during admission
• Medications to be continued after discharge

7. Follow-up Plan

• Follow-up appointments
• Referrals to specialists
• Investigations to be done as outpatient

8. Instructions for Patient

• Diet and activity restrictions
• Wound care instructions (if applicable)
• Warning signs that require immediate medical attention

9. Documentation

• Name and signature of resident or medical officer
• Consultant's name
• Date of discharge summary

Tips

• Write the summary on the day of discharge
• Be comprehensive but concise
• Ensure all medication doses are correct
• Give a copy to the patient and file one in the chart