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Ward Protocols

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