Discharge Summary
last authored: Nov 2011, David LaPierre
last reviewed:
Introduction
The discharge summary is a critical aspect of documentation and should should provide the reader with details surrounding hospitalization - how and why did the patient come to hospital? What happened while they were admitted? What tests were done, and what did they show? What treatments were provided? What was planned after discharge?
The discharge summary serves as a record for the team who will immediately be caring for the patient, as well as for health care providers in the future who may wish to refer to details. It also provides important evidence in the case of legal challenge. It is important to it is completed sufficiently quickly and with sufficient quality (Kripilani et al, 2007). The discharge summary must be well-organized, in order to ensure information is not left out and is easily searchable. We encourage you to use a standardized template, in order to streamline discharge summary creation and reading (Louden, 2009).
Components
Patient demographics
Name, age, account number.
Copies to: referring physician/family physician, as well as any other healthcare provider that is involved in the patient care or that would benefit knowing what happened to the patient while in hospital.
Admission and discharge date.
Most Responsible Diagnosis
Based on the chief complaint, with a brief attending history, physical exam, and investigations leading to diagnosis.
Post-Admit Comorbidities
These are conditions that affected impacted hospitalization, and should include complications and infections.
Pre-Admit Comorbidities
Conditions that were present prior to admission and that contributed to length of stay.
Secondary Diagnoses
Conditions that were present prior to admission and that did NOT contribute to length of stay.
Procedures and Interventions
These are to allow future care providers to understand what was done, and should include surgeries and lines. This will facilitate monitoring during followup.
Course in Hospital
Include relevant signs and symptoms, investigations, and treatments related to the above diagnoses.
Medications at discharge
It can be helpful to make bold new medications.
Condition at Discharge
It can be helpful to begin this section with "In summary" in order to prime readers who are scanning the page. Include active problem list and vitals, relevant signs and symptoms.
Disposition
Provide clear explanations of next steps, including:
- who will be responsible for care, and where
- pending investigations
- functional, nursing, and rehabilitative needs, and what has been set up
Examples (Fictitious Cases)
- adult pneumonia
- pediatric diarrhea
- Caesarean section
Adult Pneumonia
Patient demographics
John Sampson, DOB Oct 17, 1952
hospital number 12345678
Date of admission: Nov 13, 2011
Date of discharge: Nov 15, 2011
Most Responsible Diagnosis
right middle lobe pneumonia
Post-Admit Comorbidities
none
Pre-Admit Comorbidities
diabetes mellitus
smoking
Secondary Diagnoses
osteoarthritis
Procedures and Interventions
IV access obtained
Course in Hospital
Mr Sampson was admitted with a 3 day history of worsening cough, shortness of breath, chest pain, and fever. At admission, his pulse was 126 and oxygen saturation was 88%. White blood cell count was 18. ECG and troponin were normal. Chest X-ray revealed R middle lobe pneumonia, and IV ceftriaxone was started. Blood cultures revealed Streptococcus penumoniae. Mr Sampson responded rapidly to antibiotic therapy, and oxygen requirements decreased after one day. He remained afebrile and his white blood cell count normalized on Nov 14. He was switched to oral antibiotics successfully and discharged home on Nov 15.
Medications at discharge
metformin 500mg BID
rampiril 5mg daily
cefuroxime 500mg BID x 5 days (new medication)
Condition at Discharge
As described, Mr Sampson's vitals and WBC count normalized at time of discharge. His cough persisted, but was much less productive. His shortness of breath and chest pain had resolved.
Disposition
Mr Sampson was discharged home with his wife. He is fully independent. He is to follow up with his family physician in 7-10 days to ensure clinical resolution and to discuss smoking cessation. Chest X-ray is to be done after one month to assess lungs, including for malignancy.
Mr Sampson was advised to return to hospital if his symptoms return.
Pediatric Diarrhea
Patient demographics
Alice Shanti, DOB July 12, 2010
hospital number 87654321
Date of admission: Sept 4, 2010
Date of discharge: Sept 6, 2010
Most Responsible Diagnosis
viral gastroenteritis
Post-Admit Comorbidities
none
Pre-Admit Comorbidities
dehydration
Secondary Diagnoses
none
Procedures and Interventions
IV access
Course in Hospital
Alice was admitted to hospital after a 2 day history of significant watery diarrhea, leading to dehydration, poor feeding, and lethargy. IV access was started for rehydration. She was provided with oral rehydration along with her regular formula feeding. Lab values were normal throughout. Stool culture was negative for bacterial pathogens, including C. difficile. Diarrhea resolved after one day, and the IV was discontinued on day two. She tolerated oral feeds well and was discharged home on day three.
Medications at discharge
None
Condition at Discharge
Vitals stable, well-hydrated, alert, feeding well
Disposition
Education was provided to Alice's parents regarding oral rehydration therapy during periods of diarrhea. She is to follow up with her primary care physician in 7-10 days to assess her recovery and for her two-month well-baby visit.
Caesarean section
Patient demographics
Esther Obate, DOB April 2, 1970
hospital number 11223344
Date of admission: February 7, 2007
Date of discharge: February 12, 2007
Most Responsible Diagnosis
Caesarean section, arising from failure to progress
Post-Admit Comorbidities
wound infection
Pre-Admit Comorbidities
diabetes mellitus
Secondary Diagnoses
hypertension
Procedures and Interventions
Caesarean section
Course in Hospital
Esther was admitted to the labour and delivery ward after labour had been established for 4 hours. Over the next six hours her cervical dilation progressed to 8cm and then stopped. The fetal presentation was deemed to be transverse. Oxytocin augmentation was provided without effect. Fetal heart rate was reassuring, but after discussion with the patient and her husband, decision was made to proceed with Caesarean section.
A healthy infant was delivered, and the patient tolerated the surgery well with no complications. Blood loss was minimal. On post-op day two, the patient developed fever, and the surgical incision was found to be red and oozing. The rest of the physical exam was unremarkable. White blood cell count was 16. Intravenous clindamycin (900mg TID) and gentamicin (1.5mg/kg = 90mg TID) was provided, with resolution of the fever within 24 hours. Urine culture was negative. The patient was maintained in hospital for an additional three days for IV therapy.
Her pain was well-controlled with tylenol plus codiene and then only occasional tylenol at time of discharge. Her bowel and bladder function were normal. She was able to ambulate without difficulty and care for her child.
Medications at discharge
acetaminophen 500mg q4h PRN
polyethylene glycol 1-2 tablespoons daily as required
Condition at Discharge
Esther recovered fully from her wound infection/endometritis with IV therapy. She was discharged home with her husband and infant.
Disposition
Esther was to follow up her family physician in 3 days for staple removal and to assess her recovery. She will be following up with her obstetrician in two weeks.
Additional Resources
Kripalani S et al. 2007. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 297(8):831-41.
Louden K. 2009. Creating a better discharge summary. ACP Hospitalist.
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