Get the free Discharge Summary

Summary of the patient's hospital stay including diagnosis, treatment, and transfer details.

How to fill out discharge summary

How to fill out Discharge Summary

1. Start with patient identification details: include the patient's name, date of birth, medical record number, and admission date.
2. Summarize the patient's relevant medical history prior to admission.
3. Document the reason for admission and the course of treatment provided during the hospital stay.
4. Include details about the patient’s progress and response to treatment.
5. List any procedures performed during the hospitalization.
6. Provide discharge medications, including dosages and instructions for use.
7. Outline follow-up care instructions and any referrals to outpatient services.
8. Include any specific patient or family education provided before discharge.

Who needs Discharge Summary?

1. Patients who have been hospitalized and are being discharged from a medical facility.
2. Healthcare providers and specialists who require a summary of the patient’s hospital stay.
3. Insurance companies for billing and review purposes.
4. Research and quality assurance departments for data tracking.

People Also Ask about

How do I get a discharge summary?

You should be able to get a copy from the ward manager or the hospital's Patient Advice and Liaison Service (PALS). Once you're admitted to hospital, your treatment plan, including details for discharge or transfer, will be developed and discussed with you.

What is a discharge summary?

A discharge summary is a clinical document that summarizes a patient's hospital stay including diagnosis, procedures performed, medications prescribed, and follow-up instructions.

What is a full discharge summary?

A complete Discharge Summary is given to all the patients who are discharged from the hospital including MLC and LAMA Cases. In case of LAMA, consent is taken from the patient/next to kin mentioning the reason for LAMA.

What does a discharge summary include?

Most discharge letters include a section that summarises the key information of the patient's hospital stay in patient-friendly language, including investigation results, diagnoses, management and follow up. This is often given to the patient at discharge or posted out to the patient's home.

What information is usually included in a discharge summary?

A discharge summary document produced using the data set should provide a full picture to a patient's primary care healthcare practitioner on the inpatient stay, including patient details, admission and discharge details, clinical course during the inpatient stay, changes to medication and a full list of discharged

Who writes a discharge summary?

The attending physician or primary physician is responsible for writing and signing discharge summaries and discharge instructions, as they are in charge of the patient's care. Nurses assist in the process but do not sign off on these documents. This ensures accurate communication regarding post-discharge care.

For pdfFiller’s FAQs

What is Discharge Summary?

A Discharge Summary is a comprehensive document that outlines a patient's medical history, treatment received, and the status of their health at the time of discharge from a healthcare facility.

Who is required to file Discharge Summary?

Healthcare providers, including physicians and hospitals, are required to file a Discharge Summary for patients who have been admitted and subsequently discharged from a facility.

How to fill out Discharge Summary?

To fill out a Discharge Summary, healthcare providers should include patient identification information, admission and discharge dates, a summary of the treatment provided, medications prescribed, follow-up care instructions, and any significant clinical findings.

What is the purpose of Discharge Summary?

The purpose of a Discharge Summary is to ensure continuity of care by providing essential medical information to follow-up healthcare providers, enable accurate record-keeping, and inform the patient about their health status and post-discharge instructions.

What information must be reported on Discharge Summary?

The information that must be reported on a Discharge Summary includes patient demographics, admission and discharge diagnoses, treatment details, medications prescribed, instructions for follow-up care, and any referrals to other healthcare professionals.