A discharge summary is the hospital’s record of a stay, for the chart and the next clinician: why the patient came in, what was found and done, how they left, and every medicine change, pending result, and follow-up. Copy the free template, see a 5-day COPD exacerbation and a 9-day hip fracture stay ending in inpatient rehab, and check what to write in each part.
Blank discharge summary template
FreeDISCHARGE SUMMARY Patient: [Name] Date of birth: [Date] Medical record number: [Number] Admitted: [Date, and whether through the emergency department, a clinic, or a transfer] Discharged: [Date] Length of stay: [Days] Service and attending: [Admitting service, attending physician, and any comanaging service] Discharged to: [Home, home with services, inpatient rehabilitation, skilled nursing or long-term care, or another hospital] Primary care clinician: [Name and practice, or none, and who follows up instead] Copies to: [Family doctor, specialists following up, the receiving facility] DIAGNOSES Reason for admission: [The presenting problem, in one sentence] Main diagnosis: [The condition chiefly responsible for the stay] Other diagnoses treated: [Each problem managed during the stay] New diagnoses: [Conditions found this stay that belong on the problem list, or none] Complications: [Hospital-acquired problems such as delirium, a fall, an infection, or a kidney injury, or none] Chronic conditions: [Long-term problems, stable or changed] HOSPITAL COURSE BY PROBLEM Problem 1: [Findings on arrival, treatment, response, and where it stands at discharge] Problem 2: [Findings, treatment, response, status] Problem 3: [Findings, treatment, response, status] Chronic conditions: [What was continued, held, or adjusted, and why] PROCEDURES, CONSULTS, AND KEY RESULTS Procedures: [Each procedure, date, operator, and findings or complications, or none] Transfusions: [Product, units, date, and the reason, or none] Consultants: [Each service, the question asked, and its main advice] Key results: [The results that changed management, with dates, and the discharge values to compare against] CONDITION AT DISCHARGE Vital signs: [Temperature, heart rate, blood pressure, breathing rate, oxygen saturation and on what] Mental status: [Orientation and cognition, compared with baseline] Function: [Walking, transfers, and self-care now, and before admission] Diet, wounds, and devices: [Diet, wound state, catheters, drains, or oxygen going home] Weight: [Discharge weight, when it matters for doses or fluid] DISCHARGE MEDICINES Started: [Drug, dose, route, frequency, reason, and stop or review date] Changed: [Drug, old dose, new dose, and reason] Held: [Drug, reason, what must happen before it restarts, and who decides] Stopped: [Drug and reason, so it isn't restarted] Finished in hospital: [Short courses completed before discharge] Unchanged: [Home medicines continued as before] Allergies: [Drug and reaction, with any new ones found or labels removed this stay] PENDING RESULTS AND FOLLOW-UP Pending: [Each test, the date sent, who reviews it, and how the patient and next clinician will hear] Booked: [Clinic or clinician, date, and the purpose of each visit] Still to arrange: [Who books it, and by when] Tasks for the next clinician: [Each check or decision, with a date or a threshold] INSTRUCTIONS AND CODE STATUS Instructions given: [Activity, diet, wound care, warning signs, and the written plan handed over, to whom] Understanding: [What the patient and family said back, and the language or interpreter used] Code status and goals of care: [Decision, date, who took part, and the named decision-maker] Dictated or written by: [Name, credentials, date and time] Attending: [Name, and date reviewed]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
General medicine ward, 5-day stay, discharged home
66-year-old woman. Admitted October 19, 2026, through the emergency department; discharged October 24, 2026, after 5 days. General medicine, attending Dr. Adeyemi. Discharged home, where she lives with her husband; no home services needed. Family doctor: Dr. Nakamura. Copies to Dr. Nakamura and to the pulmonology clinic, Dr. Brandt.
Reason for admission: 4 days of worsening breathlessness and thicker, green sputum, drowsy on arrival. Main diagnosis: acute exacerbation of COPD with acute hypercapnic respiratory failure, triggered by rhinovirus. Other diagnoses treated: steroid-related high blood sugar; tobacco use, 20 cigarettes a day. New diagnoses: prediabetes, A1c 6.0%. Complications: none. Chronic conditions: COPD, FEV1 42% predicted in March 2026, on a dual long-acting inhaler; hypertension; depression.
1. COPD exacerbation: RR 30, SpO2 84% on room air, drowsy; arterial blood gas pH 7.28, PaCO2 64 mmHg, bicarbonate 29. Noninvasive ventilation in the emergency department and step-down unit for 30 hours, oxygen titrated to SpO2 88 to 92%; at 4 hours, pH 7.34 and PaCO2 55 mmHg, and more alert. Off noninvasive ventilation the evening of October 20; oxygen stopped October 22. Nebulized salbutamol and ipratropium, back to inhalers on October 21. Prednisone 40 mg daily, October 19 to 23, and amoxicillin-clavulanate 875/125 mg twice daily for 5 days, both completed in hospital. Second exacerbation in 12 months and first admission; blood eosinophils 400 cells/µL before steroids and 320 at a stable visit in June, so stepped up to triple inhaled therapy. 2. Steroid-related high blood sugar: glucose up to 13.6 mmol/L (245 mg/dL), managed with correction insulin; 6.1 to 8.4 mmol/L (110 to 151 mg/dL) since the last prednisone dose. No diabetes medicine needed. 3. Tobacco use: first cigarette within 30 minutes of waking. Counseled on 3 days; wants to quit. Nicotine patch and gum from day 1; no smoking during the stay. Chronic: hypertension controlled on amlodipine; depression stable on sertraline.
Procedures: noninvasive ventilation, October 19 to 20. Transfusions: none. Consultants: respiratory therapy for ventilation and inhaler teaching; smoking cessation counselor, October 21. Key results: chest X-ray October 19, hyperinflation with no consolidation or pneumothorax. Respiratory viral PCR positive for rhinovirus. ECG: sinus tachycardia 112, no ischemic changes; troponin normal. Blood gas on room air October 23: pH 7.40, PaCO2 48 mmHg. Discharge labs: hemoglobin 14.8 g/dL (148 g/L), creatinine 0.8 mg/dL (71 µmol/L), potassium 4.1.
Alert and back to her usual self. T 36.9 °C (98.4 °F), HR 88, BP 128/76, RR 18. SpO2 93% at rest on room air, lowest 90% walking 80 m in the hallway; no home oxygen needed now. Breathless after 1 flight of stairs, as before this illness. Scant white sputum. Walks independently; managing her own care. Eating normally.
Started: budesonide-glycopyrronium-formoterol inhaler, 2 inhalations twice daily, rinse mouth after each dose, for COPD with exacerbations and raised eosinophils; review at 3 months. Nicotine patch 21 mg every 24 hours, then step down over 8 to 10 weeks with her family doctor; nicotine gum 2 mg as needed for cravings. Changed: none. Held: none. Stopped: tiotropium-olodaterol, 2 inhalations daily, as the new inhaler contains its own long-acting antimuscarinic and beta-agonist. Finished in hospital: prednisone and amoxicillin-clavulanate; no course continues at home. Unchanged: salbutamol, also called albuterol, 2 puffs through a spacer as needed; amlodipine 5 mg daily; sertraline 50 mg daily. Allergies: codeine, nausea and vomiting, an intolerance; nothing new.
Pending: alpha-1 antitrypsin level, sent October 21, as she had never been tested. Dr. Adeyemi’s team reviews it in about 2 weeks and sends it to Dr. Nakamura and Dr. Brandt; a low level means referral for genetic testing. Booked: Dr. Nakamura, October 29, to check breathing and inhaler technique and adjust the nicotine plan. Pulmonology, Dr. Brandt, November 23, with spirometry and a room-air blood gas; persistent hypercapnia would prompt an assessment for home noninvasive ventilation. Still to arrange: pulmonary rehabilitation, referral sent October 23; the program calls her within 2 weeks. Tasks for the family doctor: offer pneumococcal and RSV vaccines; repeat A1c within a year; review long-term oxygen need once stable.
Given a written COPD action plan: when to use the reliever more often, when to call the family doctor, and to call 911 for severe breathlessness, drowsiness, confusion, or chest pain. Shown the new inhaler with a spacer; she demonstrated it back correctly. Quitline information given; her husband, who also smokes, was offered the same help. Influenza vaccine given October 22. Code status: full code, confirmed with her October 20 once alert; she would accept intubation if noninvasive ventilation failed, and wants to make an advance care plan with her family doctor. Her husband is her named decision-maker.
Orthopedic ward with geriatric comanagement, 9-day stay
81-year-old man. Admitted October 28, 2026, through the emergency department; discharged November 6, 2026, after 9 days. Orthopedic surgery, attending Dr. Varga, comanaged by geriatric medicine, Dr. Osei. Discharged to the inpatient rehabilitation unit at the hospital’s east campus; goal is to return home with his wife. Family doctor: Dr. Haddad. Copies to the rehabilitation physician, Dr. Haddad, and the fracture liaison service.
Reason for admission: tripped on a rug at night walking to the bathroom; could not stand, left leg shortened and externally rotated. Main diagnosis: left intertrochanteric hip fracture, a fragility fracture. Other diagnoses treated: acute blood loss anemia; iron deficiency; vitamin D deficiency. New diagnoses: osteoporosis, from a hip fracture after a fall from standing height. Complications: postoperative delirium, resolved; acute kidney injury, recovering; urinary retention, resolved. Chronic conditions: hypertension; type 2 diabetes; benign prostatic hyperplasia; overactive bladder; hearing loss, uses hearing aids.
1. Hip fracture: fascia iliaca block in the emergency department. Cephalomedullary nail on October 29 under spinal anesthesia, 22 hours after arrival. Weight-bearing as tolerated from day 1. Physiotherapy twice daily: stood on day 1, now walks 15 m with a walker. Enoxaparin from the morning after surgery. 2. Postoperative delirium: October 29 to November 1, CAM positive, worse at night, pulling at his IV. Contributors found: pain, urinary retention, constipation, hearing aids left at home, and two anticholinergic medicines. Managed without antipsychotics: hearing aids and glasses brought in, family visits, a day-night routine, bladder drainage, and bowels opened. 4AT 0 since November 2; his wife says he is himself again. 3. Acute blood loss anemia: hemoglobin 12.9 g/dL (129 g/L) on admission, 7.6 g/dL (76 g/L) on October 30 with dizziness on standing; 1 unit of red cells, then 8.8 g/dL (88 g/L). Ferritin 42 ng/mL, transferrin saturation 13%: oral iron started. 4. Acute kidney injury: creatinine 1.1 mg/dL (97 µmol/L) at baseline, 1.6 mg/dL (141 µmol/L) on October 30 with low blood pressure and poor intake. Ramipril held, IV fluids given; 1.2 mg/dL (106 µmol/L) on November 5. Metformin held October 30, restarted November 3. 5. Urinary retention: 900 mL on bladder scan October 30; catheter for 3 days, oxybutynin stopped, tamsulosin continued; voiding since removal, residuals under 150 mL. 6. Bone health: vitamin D 18 ng/mL (45 nmol/L), calcium normal; vitamin D3 started, zoledronic acid planned after repletion.
Procedures: left cephalomedullary nail, October 29, Dr. Varga; spinal anesthesia; estimated blood loss 350 mL; no complications. Fascia iliaca block, October 28. Urinary catheter, October 30 to November 2. Transfusions: 1 unit of red cells, October 30, for hemoglobin 7.6 g/dL with symptoms. Consultants: geriatric medicine, comanaging from admission; physiotherapy and occupational therapy daily; dietitian, October 31, for poor intake, started oral supplements. Key results: postoperative X-ray, nail in good position. ECG: sinus rhythm with first-degree AV block, unchanged from 2024. Urine culture October 30: no growth. Discharge labs November 5: hemoglobin 9.4 g/dL (94 g/L), creatinine 1.2 mg/dL, sodium 137, potassium 4.4; estimated creatinine clearance about 48 mL/min at 70 kg.
Alert and oriented, 4AT 0, conversing normally with hearing aids in. T 36.7 °C (98.1 °F), HR 76, BP 132/74 lying and 124/70 standing, SpO2 96% on room air. Pain 2 out of 10 at rest, 4 on walking. Walks 15 m with a front-wheeled walker and one person standing by; transfers with one person helping; needs help with lower-body dressing and bathing. Before the fall: walked outdoors with a cane, independent in self-care, in a bungalow with 3 steps to the door. Incisions clean and dry, staples in. Eating half to three quarters of meals, plus supplements. Bowels open November 4 and 5. Weight 70 kg.
Started: enoxaparin 40 mg subcutaneously daily until December 3, 35 days after surgery, to prevent clots. Acetaminophen 1 g by mouth every 8 hours, regularly, no more than 3 g a day. Oxycodone 2.5 mg every 4 hours as needed for pain on walking, used twice in the past 24 hours; rehab team to taper and stop. Senna 2 tablets at night and polyethylene glycol 17 g daily while on oxycodone. Vitamin D3 2,000 units daily. Ferrous sulfate, 1 tablet every other day, for iron deficiency. Oral nutrition supplement twice daily. Changed: none. Held: ramipril 10 mg daily, since October 30, for kidney injury and low blood pressure; restart at 5 mg if creatinine stays at 1.3 mg/dL (115 µmol/L) or below and systolic pressure is above 130; the rehab physician decides. Stopped: oxybutynin 5 mg twice daily, as an anticholinergic it likely added to his delirium and urinary retention. Diphenhydramine 50 mg at night, bought for sleep: stopped for the same reason. Unchanged: amlodipine 5 mg daily, metformin 500 mg twice daily, tamsulosin 0.4 mg daily, atorvastatin 20 mg daily. Allergies: sulfonamide antibiotics, rash; nothing new.
Pending: serum protein electrophoresis, sent November 4, to look for a secondary cause of osteoporosis. Dr. Osei reviews it and phones the rehab physician if it is abnormal; the fracture liaison nurse checks it before the zoledronic acid visit. Booked: staple removal November 12, 14 days after surgery, by rehab nursing. Fracture liaison service, November 26: recheck calcium and vitamin D, then zoledronic acid 5 mg IV if both are adequate and creatinine clearance is 35 mL/min or more. Fracture clinic, December 10, 6 weeks after surgery, with an X-ray. Tasks for the rehab team: creatinine and potassium on November 10, then the ramipril decision; hemoglobin in 1 week; falls and home safety assessment before he goes home. Task for the family doctor: cognitive screen 3 months after discharge, as delirium can mark an underlying cognitive problem; review bladder symptoms without anticholinergics.
Explained to him and his wife, with hearing aids in: walker at all times; full weight on the leg; no hip movement limits after a nail; commode and night light by the bed. For rehab staff: new confusion, calf swelling, breathlessness, or wound redness or discharge need same-day medical review. His wife repeated the plan back. Code status: do not attempt resuscitation; all other treatment continues, including transfer to hospital. Decided by him on November 3, with capacity once the delirium had cleared, with his wife and daughter present. His wife is his named decision-maker. The order goes with him to rehabilitation.
Who, when, under whom, and where the patient went. A reader opening the chart months later should know the shape of the stay from these lines alone.
Avoid: Leaving out the discharge destination. A rehab unit or a long-term care home reads the summary differently from a family doctor, and needs to know it was written for them.
The main diagnosis first, then everything else treated, found, or acquired during the stay, each on its own line.
Avoid: Carrying an admission working diagnosis to discharge. If “possible pneumonia” was ruled out, write what it turned out to be.
One short paragraph per problem: what you found, what you did, how the patient responded, and where it stands now. This is the part the next clinician reads to understand the stay.
Avoid: A day-by-day diary. Readers want the arc of each problem, not what happened on Tuesday.
What was done to the patient, who else gave advice, and the results that drove decisions.
Avoid: Pasting every lab result. Give the results that changed management, and the last value of anything still being followed.
How the patient left, measured, so the next clinician can tell at once whether they are better or worse.
Avoid: “Stable for discharge.” Stable at what? Write the numbers and the function the next team will measure against.
The reconciled list, sorted by what happened to each medicine, with the reason beside every change.
Avoid: “Resume home medications.” It hides every hold and every stop, and the home list it points to is often out of date.
Everything still open when the patient leaves, each with a name beside it.
Avoid: A pending test with no owner. Results that return after discharge go to whoever ordered them, who may be off service by then.
What the patient was told, what they understood, and the resuscitation decision that goes with them.
Avoid: Leaving the code status in the progress notes. A decision made on day 6 must travel to the rehab unit or nursing home in the summary.
A single paragraph that runs from arrival to discharge buries the decisions. Split the course by problem, so a reader looking for the kidney injury finds it in one place.
Delirium, a transfusion, a fall, or a kidney injury often matter more to the next clinician than the main diagnosis. Post-operative delirium, for one, flags a person at risk of cognitive decline. List each one under complications, and in the course.
It hides the inhaler that was replaced, the blood pressure pill on hold, and the sleep aid that should never come back. Sort every medicine into started, changed, held, stopped, or unchanged, each with its reason.
A held medicine with no restart condition stays held for years, or is restarted too soon. Write what must happen first, such as a creatinine at or below a value, and who makes the call.
A summary finished a week late arrives after the family doctor has already seen the patient. Write it on the day of discharge, or send a short interim summary and complete the full one after.
Vero Scribe drafts the discharge summary in your template from your dictation, or from the discharge conversation with the patient’s consent. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Start with the stay details and the diagnoses, main one first. Write the hospital course one problem at a time: findings, treatment, response, and status at discharge. Then list procedures, consults, and key results, the condition at discharge with numbers, the medicines sorted into started, changed, held, stopped, and unchanged with reasons, every pending result with its owner, the follow-up, and the code status. The two examples on this page show the template filled in.
The discharge summary is the full clinical record of the stay, for the chart and any clinician who needs the detail. The discharge letter is a one-page note to the family doctor with requests, medicine changes, and pending results up front. Discharge instructions are the patient’s plan, in everyday words. Many hospitals produce all three from the same facts, so check that they agree before the patient leaves.
As long as the stay needs, and no longer. A 2-day uncomplicated admission may fit on a page; a long stay with complications runs to two or three. Keep it short by writing the course by problem, giving the results that changed management rather than every value, and leaving daily detail in the progress notes.
The deadline comes from your hospital’s rules, your regulator, and the law where you practice, and they differ: some ask for the summary within 48 hours, others allow up to 30 days to complete the record. The next clinician needs it sooner, so finish it on the day the patient leaves where you can, or send a short interim summary first.
Yes. Copy it, or download it as a Word or text file. No account needed.
The daily inpatient note: overnight events, trends, a plan by problem, and the daily checklist.
The full adult admission workup, with medication reconciliation, goals of care, and level of care.
Answer another team’s question: a focused history, a direct answer, and numbered recommendations.
The note that moves with the patient between units or hospitals: reason, course, problems, devices, and who follows what.
The one-page letter to the family doctor at discharge: requests with dates, medicine changes, and pending results.
How to check a summary before it goes out: a handoff review exercise, reconciliation tables, and a quality checklist.
How Vero turns your account of the stay into a summary draft for your review.
Check the medicine list before you sort it into started, changed, and stopped.
Admissions, daily notes, and discharge documents, drafted for your review.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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