Discharge Summary Template

Hospital discharge summary: diagnoses, procedures, hospital course, medication reconciliation, follow-up, pending results

의료표준discharge summary업데이트됨 2026. 10. 20.

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사용법: Use at the end of an inpatient stay to hand over to primary care and the patient. Fill medication changes and pending results first, as these drive follow-up. Main pitfall: unreconciled medications or pending results with no named owner; placeholders only, follow local privacy law.

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Discharge Summary: [Patient ID placeholder]

Hospital discharge summary for handover from the inpatient team to the patient's primary care clinician and the patient: admission details, diagnoses, procedures, hospital course, medication reconciliation, follow-up, pending results and instructions. Based on common clinical documentation practice. This is a documentation format, not clinical advice. Use placeholders only in this template, and follow local privacy law (for example HIPAA or GDPR) and your institution's documentation policy when completing a real record.

Field	Value
Patient name	[Patient name]
Patient identifier	[MRN / health number]
Date of birth	[YYYY-MM-DD]
Admission date	YYYY-MM-DD
Discharge date	YYYY-MM-DD
Length of stay	[n] days
Admitting service / ward	[Service, ward]
Responsible consultant / attending	[Name, role]
Discharge destination	[Home / home with services / rehabilitation / care facility]
Summary sent to	[Primary care clinician, practice]

1. Reason for admission

[Presenting complaint, route of admission (emergency, elective, transfer) and the main clinical question at admission.] Example: Admitted via the emergency department with three days of worsening breathlessness and productive cough.

2. Diagnoses

Type	Diagnosis	Code (if used)	Status at discharge
Principal	[Diagnosis]	[ICD-10 / SNOMED CT]	[Resolved / improving / ongoing]
Secondary	Example: [Acute kidney injury, stage 1]	[Code]	[Resolved]
Secondary	[Diagnosis]	[Code]	[Status]
Comorbidity	[Pre-existing condition]	[Code]	[Stable]

3. Procedures and key investigations

Date	Procedure or investigation	Key result
YYYY-MM-DD	[Procedure]	[Outcome, complications]
YYYY-MM-DD	[Imaging]	[Key finding]
YYYY-MM-DD	[Laboratory trend]	Example: [Marker] peaked on day 2, normal by discharge

4. Hospital course

Summarise the course by problem:

[Problem 1]: [Treatment given, response, complications.]
[Problem 2]: [Treatment given, response.]
[Problem 3]: [Treatment given, response.]

Example of a problem entry: [Community-acquired pneumonia]: Treated with [antibiotic] per local guideline, switched to oral on day 3 when afebrile and eating. Oxygen weaned off by day 4. No complications. Complete a 5-day course in total.

Changes to long-term management: [New diagnoses, new long-term medications, changes to care needs or equipment, advance care planning discussions and their outcome, and any change in resuscitation status that the receiving clinician must know about.]

Social and functional changes: [Mobility aids issued, package of care started or increased, carer arrangements, home adaptations requested, and whether these were in place on the day of discharge.]

Condition at discharge: [Functional status, mobility, cognition, vital signs within expected range for this patient, diet tolerated.]

5. Allergies and adverse reactions

Substance	Reaction	Severity	New this admission?
[Substance]	[Reaction]	[Mild / moderate / severe]	[Yes / No]

6. Medications on discharge

Medication reconciliation:

Medication	Dose, route, frequency	Status	Reason for change	Duration / review
[Medication A]	[Dose, route, frequency]	Continued, unchanged	Not applicable	Ongoing
[Medication B]	[New dose]	Dose changed	[Reason]	[Review date]
[Medication C]	[Dose]	New	[Indication]	Example: 5 more days, stop on YYYY-MM-DD
[Medication D]	Not applicable	Stopped	[Reason]	Do not restart without review
[Medication E]	[Dose]	Withheld temporarily	[Reason]	[Restart criteria]

Supply given: [days of each medication supplied]. Compliance aids: [blister pack, carer support].

7. Follow-up appointments

With	Purpose	When	Booked by
[Primary care clinician]	[Review symptoms, repeat blood test]	[Within 7 days]	[Patient / practice]
[Specialty clinic]	[Purpose]	[Date or interval]	[Hospital]
[Community service]	[Purpose]	[Start date]	[Referral sent YYYY-MM-DD]

8. Pending results and actions for the receiving clinician

Test or action	Expected by	Responsible for follow-up	Action if abnormal
[Culture result]	YYYY-MM-DD	[Hospital team / primary care]	[Action]
[Histology]	YYYY-MM-DD	[Team]	[Action]
[Action requested of primary care]	[Timeframe]	[Primary care clinician]	Not applicable

9. Information given to the patient

The patient [and carer] received the following information:

Diagnosis and what it means: [plain-language summary given]
Medication changes explained: [Yes / No; written list provided]
Activity, diet and wound care: [Instructions]
Warning signs that need urgent review: [List, for example worsening breathlessness or fever]
Who to contact: [Ward phone, out-of-hours service]
Fitness to work or drive: [Advice given and certificate issued]

10. Clinician details

Field	Value
Completed by	[Name, role, registration number]
Responsible consultant / attending	[Name]
Contact	[Team phone or secure message route]
Date and time completed	YYYY-MM-DD HH:MM
Copies sent to	[Primary care, patient, other services]

Standard and licence note

Based on common clinical documentation practice for hospital discharge summaries. Check national or institutional standards that apply to your setting, such as the record headings adopted by your health system. This is a documentation format, not clinical advice; follow local privacy law and your institution's documentation policy. Template licence: MIT.