Hospital Discharge Summary Report

What is hospital discharge summary report?

A hospital discharge summary report is a document that provides an overview of a patient's stay in the hospital and their medical condition upon discharge. It includes important information such as the reason for admission, diagnoses, treatments received, medications prescribed, and follow-up instructions. The discharge summary report serves as a communication tool between healthcare providers and ensures continuity of care for the patient.

What are the types of hospital discharge summary report?

There are two main types of hospital discharge summary reports:

Standard Discharge Summary Report:
This type of report includes essential information about the patient's hospitalization, medical history, treatment provided, and post-discharge care instructions. It is commonly used for routine patient discharges.
Detailed Discharge Summary Report:
This type of report provides a more comprehensive overview of the patient's hospital stay, including detailed information about the treatment plan, surgical procedures performed, test results, and any complications experienced. It is often used for complex medical cases or when a patient requires ongoing care or specialist follow-up.

How to complete hospital discharge summary report

Completing a hospital discharge summary report requires attention to detail and accuracy. Here are the steps to follow:

01
Gather all relevant patient information, including medical history, diagnosis, and treatment details.
02
Document the reason for admission and the patient's response to treatment.
03
Include a list of medications prescribed and any changes made during the hospital stay.
04
Summarize the patient's condition at the time of discharge, including any follow-up care or recommendations.
05
Proofread and review the report for any errors or missing information.
06
Ensure the report is signed and dated by the responsible healthcare provider.

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Questions & answers

6 Components of a Hospital Discharge Summary Reason for hospitalization: description of the patient's primary presenting condition. and/or. Significant findings: Procedures and treatment provided: Patient's discharge condition: Patient and family instructions (as appropriate): Attending physician's signature:
Hospital discharge summaries serve as the primary documents communicating a patient's care plan to the post-hospital care team. 1, 2. Often, the discharge summary is the only form of communication that accompanies the patient to the next setting of care.
6 Components of a Hospital Discharge Summary Reason for hospitalization: description of the patient's primary presenting condition. and/or. Significant findings: Procedures and treatment provided: Patient's discharge condition: Patient and family instructions (as appropriate): Attending physician's signature:
To continue to paraphrase the APTA's description: All discharge summaries should include patient response to treatment at the time of discharge and any follow-up plan, including recommendations and instructions regarding the home program if there is one, equipment provided, and so on.
A discharge summary should contain a sufficient level of information to ensure that both patients and other healthcare professionals are aware of the relevant events of a hospital admission. 1 2 The transition between different levels of care represents a potential area where patient care is at risk.
Clinical Summary – An after-visit summary that provides a patient with relevant and actionable information and instructions containing the patient name, provider's office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions