How to Write a Discharge Summary with Template and Examples
Updated: April 22, 2024Discharge summaries are essential documents that ensure continuity of care from hospital to outpatient settings. Let’s review how to create effective discharge summaries and create a standardized template to enhance documentation practices among healthcare professionals.
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What is a Discharge Summary?
A discharge summary is a comprehensive document detailing a patient’s hospital stay from admission to discharge. It outlines the reasons for admission, treatments administered, clinical outcomes, and specific plans for follow-up care.
Functionality
Crafted primarily by the attending physician, this document serves as a crucial communication tool for subsequent care providers, offering insights into the patient’s acute hospital course, aiding in ongoing care management, and anticipating potential health issues.
Characteristics of an Effective Discharge Summary
An effective discharge summary is succinct yet comprehensive, accurately reflecting the patient’s health status and treatment trajectory. Key elements include:
- Clear, concise descriptions of diagnoses and interventions
- accounts of medication adjustments
- Specifics of the follow-up care plan
Clear, detailed, and specific summaries ensure seamless care transitions and help prevent clinical oversights.
Importance of a Discharge Summary
Discharge summaries are vital for several reasons:
- Clinical Accuracy: They minimize the risk of clinical errors during care transitions by providing a detailed account of the hospital stay.
- Continuity of Care: They furnish a blueprint for ongoing treatment, which is crucial for outpatient providers and specialists.
- Communication Enhancement: They facilitate robust information exchange between varying healthcare entities involved in patient care.
Effectively, these summaries not only streamline patient management but also contribute to improved health outcomes.
Benefits of Using a Discharge Summary Template
Implementing a discharge summary template offers numerous benefits:
- Streamlined Documentation: Templates standardize the capture of essential clinical data, enhancing the efficiency of the documentation process.
- Consistency: A uniform structure ensures that all pertinent information is consistently recorded, reducing variability in patient records.
- Comprehensive Coverage: Templates help in systematically documenting critical information, thus reducing the chances of omissions that could impact patient care.
Templates not only aid in maintaining high standards of clinical documentation but also ensure that all relevant details are communicated effectively to all subsequent care providers.
Discharge Summary Template and Examples
Below is a standardized discharge summary template and three examples. You can follow this template to ensure comprehensive documentation with enough context to aid in the communication between healthcare providers.
Discharge Summary Template
Name: [Insert name]
Admission Date: [Insert date]
Discharge Date: [Insert date]
Date of Birth: [Insert DOB]
Sex: [Insert sex]
History of Present Illness: [Detailed clinical presentation]
Past Medical History: [Comprehensive listing of relevant past medical conditions]
Past Diagnosis: [Relevant past diagnoses]
Brief Hospital Course: [Detailed account of the treatment provided and patient’s response]
Medications at Admission: [Detailed listing of medications and dosages at admission]
Discharge Medications: [Detailed listing of medications and dosages at discharge]
Follow-up Plans: [Specific plans for follow-up care, including appointments and therapeutic considerations]
Examples
Example 1: Gastroenteritis
Name: John Doe
Admission Date: January 1, 2024
Discharge Date: January 5, 2024
Date of Birth: July 7, 1990
Sex: Male
History of Present Illness: Presented with severe abdominal pain and vomiting.
Past Medical History: Type 2 diabetes.
Past Diagnosis: Gastroenteritis.
Brief Hospital Course: Treated with IV fluids and antibiotics. Symptoms improved steadily.
Medications at Admission: Metformin.
Discharge Medications: Metformin continued, new prescription for a proton pump inhibitor.
Follow-up Plans: Follow-up with a gastroenterologist in one week; monitor blood sugar levels regularly.
Example 2: Asthma
Name: Jane Smith
Admission Date: March 12, 2024
Discharge Date: March 18, 2024
Date of Birth: November 15, 1985
Sex: Female
History of Present Illness: Shortness of breath and chest pain.
Past Medical History: Hypertension.
Past Diagnosis: Asthma.
Brief Hospital Course: Diagnosed with pneumonia, treated with antibiotics and supplemental oxygen.
Medications at Admission: Lisinopril.
Discharge Medications: Lisinopril, new antibiotic course.
Follow-up Plans: Chest X-ray in two weeks; primary care follow-up within three days.
Example 3: Migraine
Name: Alice Johnson
Admission Date: May 10, 2024
Discharge Date: May 15, 2024
Date of Birth: January 22, 1970
Sex: Female
History of Present Illness: Sudden onset of severe headache and dizziness.
Past Medical History: None.
Past Diagnosis: Migraine.
Brief Hospital Course: Underwent MRI, results normal. Symptoms managed with medication.
Medications at Admission: None.
Discharge Medications: Prescription for sumatriptan.
Follow-up Plans: Neurology follow-up within one month; monitor symptoms and triggers.
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