DISCHARGE 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]