Professional Documents
Culture Documents
Discharging patients from a hospital is a complex task. An essential part of this process is
the documentation of a discharge summary. A discharge summary is a clinical report
prepared by a health professional at the conclusion of a hospital stay or series of treatments.
It is often the primary mode of communication between the hospital care team and aftercare
providers. It is considered a legal document and it has the potential to jeopardize the
patient’s care if errors are made. Delays in the completion of the discharge summary are
associated with higher rates of readmission, highlighting the importance of successful
transmission of this document in a timely fashion.
This guide will help you to understand what’s necessary to include and give you a structure
to effectively write discharge summaries. It gives a detailed description of each section that
may be included in a typical discharge summary. Each section illustrates key pieces of
information that should be included and aims to explain the rationale behind each part of the
document.
In practice, each summary is adapted to the clinical context. As such, not all information
included in this guide is relevant and needs to be mentioned in each discharge summary. In
addition, different hospitals have different criteria to be included and you should always
follow your hospital’s or medical school’s guidelines for documentation.
Demographics
Patient details
Important information to include regarding the patient includes:
Patient name: full name of the patient (also the patient’s preferred name if relevant)
Date of birth
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Unique identification number
Patient address: the usual place of residence of the patient
Patient telephone number
Patient sex: sex at birth (this determines how the individual will be treated clinically)
Gender: the gender the patient identifies with
Ethnicity: ethnicity as specified by the patient
Next of kin/emergency contact: full name, relationship to the patient and contact
details
GP details
This section should be completed with the details of the General Practitioner with whom the
patient is registered:
Hospital details
This section should encompass the salient aspects of the patient’s discharge:
Discharging consultant: the consultant responsible for the patient at the time of
discharge
Discharging specialty/department: the specialty/department responsible for the
patient at the time of discharge
Date and time of admission and discharge
Discharge destination: destination of the patient on discharge from hospital (e.g.
home, residential care home)
Clinical details
Presentation
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“Mrs Smith presented to A&E with worsening shortness of breath and ankle swelling.
On arrival, she was tachypnoeic and hypoxic (oxygen saturation 82% on air). Clinical
examination revealed reduced breath sounds and dullness to percussion in both lung
bases. There was also a significant degree of lower limb oedema extending up to the
mid-thigh bilaterally.”
Investigations
“A renal tract ultrasound has been requested and will be performed in the next 2
weeks. We will write to you with the results.”
Diagnoses
This section should include the diagnosis or diagnoses that were made during the patient’s
stay in hospital:
“Mrs Smith was reviewed by the Cardiology team who confirmed a diagnosis of
congestive heart failure.”
If no diagnosis was confirmed, use the presenting complaint and explain no cause was
identified:
“No clear cause was identified for the patient’s chest pain at this time.”
Management
Explain how the patient was managed during their hospital stay and include any long term
management that has been initiated:
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“Mrs Smith required oxygen and intravenous diuretic therapy for the first 24 hours of
her admission. She was then weaned off oxygen and commenced on regular oral
furosemide (40mg OD) which is to be continued after discharge. At discharge, Mrs
Smith’s symptoms were much improved and she was able to mobilise independently
with only mild shortness of breath on exertion.”
Complications
Document any complications that occurred during the patient’s hospital stay:
“Mrs Smith developed a stage 2 acute kidney injury after initiation of diuretic therapy,
however, this resolved with dose titration and careful fluid balance management. Her
baseline creatinine at discharge was 74 μmol/ L.”
Procedures
This section must include all operations or procedures that the patient underwent:
Future management
Include details of the current plan to manage the patient and their condition(s) after
discharge from hospital:
Clearly document any actions you would like the patient’s GP to perform after discharge:
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“Could you please arrange for Mrs Smith’s U&Es to be assessed in 2 weeks time, to
ensure her creatinine and electrolytes remain stable on her new diuretic regime.
Should you have any questions or concerns in the meantime, please don’t hesitate to
contact our team.”
Medications
Medication changes
Summarise any changes to the patient’s regular medication and provide an explanation
as to why the changes were made if possible:
You should include a list of all medications that the patient is currently taking, including:
Regular medications
As required (PRN) medications
For each medication, you should include details regarding the following:
Name: usually, generic drug names are preferred, but in some cases using the specific
brand name is more appropriate (e.g. epilepsy medication)
Form: capsule, drops, tablet, lotion, etc
Route: oral, inhaled, topic, intravenous, etc
Frequency: once daily, twice daily, as required, etc
Duration: x days, long-term, etc
Indication: e.g. congestive heart failure
Additional instructions: review date, monitoring requirements, etc
Causative agent: the agent (food, drug or substances) that caused an allergic reaction
or adverse reaction
Description of the reaction: this may include the manifestation (e.g. rash), type of
reaction (allergic, adverse, intolerance) and the severity of the reaction
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Date first experienced: when the reaction was first experienced
“You were admitted to hospital because of worsening shortness of breath and swelling of
your ankles. We performed a number of tests which revealed that your heart wasn’t pumping
as effectively as it should have been. As a result, we have started you on a water tablet
called Furosemide, which should help to prevent fluid from building up in your legs and
lungs. You should continue to take the Furosemide tablet as prescribed, however, if you
become unwell, you should see your GP as this tablet can potentially damage your kidneys if
you become dehydrated. We plan to review you in 6 weeks time, in the Cardiology
Outpatient Clinic and we will send your appointment details out in the post. We have also
asked your GP to take some blood tests to check your kidney function in around 2 weeks
time. In the meantime, should you have any concerns or questions, you should see your
GP.”
Name
Designation or role
Grade
Specialty
Date completed
Assessment scales
This section identifies any assessment scales used when clinically evaluating the patient.
Some examples of assessment scales commonly used include:
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Mood assessment scales
Malnutrition Universal Screening Tool (MUST)
Social context
Home circumstances:
Who the patient lives with (e.g. lives alone, lives with a partner, lives with family)
Details of the patient’s residence (e.g. house with stairs, bungalow, flat, residential
care, etc)
Occupational history:
Special requirements
Document if the patient has any special requirements:
Participation in research
This is to clearly identify patients who are involved in a clinical trial.
Legal information
This section describes the care of the patient from a legal perspective. Some examples of
the types of information it may include are shown below.
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Whether an assessment of the mental capacity of the (adult) patient has been
undertaken, if so, who carried it out, when it was carried out and the outcome of the
assessment
Whether there are written documents, completed and signed when a person is legally
competent, that explains a person’s medical wishes in advance, allowing someone else
to make treatment decisions on his/her behalf late in the disease process
Location of these documents
A copy of the document itself
Safeguarding issues:
Any legal matters relating to the safeguarding of a vulnerable child or adult (e.g. child
protection plan, a child in need plan, protection of a vulnerable adult)
Safety alerts
This section illustrates if the patient poses a risk to themselves, for example, suicide,
overdose, self-harm, self-neglect. Also include if the patient is a risk to others, including
professionals or any third party.
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References
1. Health and Social Care Information Centre, Academy of Medical Royal Colleges.
Standards for the clinical structure and content of patient records [Internet]. London:
Health and Social Care Information Centre, Academy of Medical Royal Colleges; 2013
p. 37 – 44. Available from: [LINK]
2. UpToDate [Internet]. Uptodate.com. 2019 [cited 28 January 2019]. Available from:
[LINK]
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