# 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.

<!--
Guidance: How to use this template
- Write for the clinician who will see the patient next, often within
  days and without access to the hospital record. Lead with what they must
  act on: medication changes, pending results, follow-up.
- Reconcile medications line by line against the pre-admission list. Every
  stopped or changed drug needs a reason.
- Complete and send the summary on the day of discharge where possible.
- In a real record, use your electronic health record's approved form and
  identifiers; never copy patient data into unapproved tools.
-->

| 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

<!-- Guidance: One or two sentences on the presenting problem and how the patient arrived, in plain terms. -->

[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

<!-- Guidance: The principal diagnosis is the condition chiefly responsible for the admission. List secondary diagnoses that affected care or need follow-up. Use coded terms if your system requires them. -->

| 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

<!-- Guidance: List procedures with dates and key findings. Summarise investigations that changed management; do not paste every result. -->

| 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

<!-- Guidance: A short narrative by problem, not a day-by-day diary. Cover what was done, the response, complications and the condition at discharge. -->

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

<!-- Guidance: Record new reactions identified during this admission and confirm pre-existing ones. "No known allergies" must be an explicit statement, not a blank. -->

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

## 6. Medications on discharge

<!-- Guidance: Reconcile against the medication list before admission. State the change for every line and the reason for every change. Give duration for short courses. -->

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

<!-- Guidance: Say who is responsible for booking each appointment. Unclear ownership is a common cause of missed follow-up. -->

| 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

<!-- Guidance: List every result not available at discharge and who will act on it. This is a frequent source of harm when omitted. -->

| 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

<!-- Guidance: Record what the patient and carers were told, in plain language, including warning signs and who to contact. -->

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

<!-- Guidance: The receiving clinician must be able to reach someone who knows the patient. -->

| 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.