/clinical-reports

Discharge Summary Template

Patient Information

Patient Name: [Last, First]
Medical Record Number: [MRN]
Date of Birth: [MM/DD/YYYY]
Age: [years]
Sex: [M/F]

Admission Date: [MM/DD/YYYY]
Discharge Date: [MM/DD/YYYY]
Length of Stay: [X days]

Admitting Service: [Medicine/Surgery/Cardiology/etc.]
Attending Physician: [Name]
Primary Care Physician: [Name and contact]
Consulting Services: [List specialties that saw patient]

Admission Diagnosis

[Primary reason for hospitalization]

Example: "Acute decompensated heart failure"

Discharge Diagnoses

[Numbered list, prioritized by clinical significance]

Primary Diagnosis:

1. [Primary diagnosis with ICD-10 code]

Secondary Diagnoses: 2. [Secondary diagnosis with ICD-10 code] 3. [Additional diagnosis with ICD-10 code] 4. [Comorbidity with ICD-10 code]

Example:

1. Acute decompensated heart failure (I50.23)
2. Acute kidney injury on chronic kidney disease stage 3 (N17.9, N18.3)
3. Hypokalemia (E87.6)
4. Type 2 diabetes mellitus (E11.9)
5. Coronary artery disease (I25.10)

Hospital Course

[Comprehensive yet concise narrative of hospital stay - can be organized chronologically or by problem]

Chronological Format:

[Date Range or Hospital Day 1-X]:

[Patient Name] was admitted to the [service] service with [chief complaint/presenting problem]. On presentation, patient was [clinical status]. Initial workup revealed [key findings].

[Description of key events, interventions, and response to treatment organized by day or by problem]

Hospital Day 1: [Events and interventions]

Hospital Day 2-3: [Progression, response to treatment]

Hospital Day 4-7: [Continued treatment, consultations, procedures]

Final Hospital Days: [Stabilization, preparation for discharge]

Problem-Based Format (Alternative):

1. [Primary Problem]

• Presentation and initial management
• Diagnostic workup
• Treatment course
• Response and outcome
• Status at discharge

2. [Secondary Problem]

• [Similar structure]

3. [Additional Problems]

Key Events and Interventions

Consultations Obtained:

• [Specialty] consulted on [date] for [reason]: [Recommendations]

Procedures Performed:

• [Procedure name] on [date]: [Indication, findings, complications if any]

Significant Diagnostic Studies:

• [Test/imaging] on [date]: [Key findings relevant to discharge care]

Complications:

• [Any complications that occurred]: [How managed]

Procedures Performed During Hospitalization

1. [Procedure name] ([Date])

   • Indication: [Why performed]
   • Findings: [Key findings]
   • Complications: [None / specific complications]

2. [Additional procedures]

Hospital Course Summary (Brief Version)

[One paragraph summary suitable for quick reference]

Example:

Mr. [Name] was admitted with acute decompensated heart failure in the setting of 
medication non-adherence. He was diuresed with IV furosemide with net negative 
5 liters over 3 days, with significant improvement in dyspnea and resolution of 
lower extremity edema. Echocardiogram showed EF 30%, similar to prior. Kidney 
function improved to baseline with diuresis. He was transitioned to oral diuretics 
on hospital day 3 and remained stable. Patient was ambulating without dyspnea on 
room air by discharge. Comprehensive heart failure education was provided.

Discharge Physical Examination

Vital Signs:

• Temperature: _____ °F
• Blood Pressure: _____/_____ mmHg
• Heart Rate: _____ bpm
• Respiratory Rate: _____ breaths/min
• Oxygen Saturation: _____% on [room air / O2]
• Weight: _____ kg (Admission weight: _____ kg)

General: [Appearance, distress level]

Cardiovascular: [Heart sounds, edema]

Pulmonary: [Breath sounds, work of breathing]

Abdomen: [Tenderness, bowel sounds, distention]

Extremities: [Edema, pulses]

Neurological: [Mental status, focal deficits]

Wounds/Incisions (if applicable): [Healing status]

Pertinent Laboratory and Imaging Results

Discharge Labs ([Date])

Imaging/Diagnostic Studies

[Study name] ([Date]): [Key findings relevant to outpatient management]

Discharge Medications

[Complete list with clear indication of changes from admission]

New Medications (Started During Hospitalization)

1. [Medication name] [dose] [route] [frequency]
   • Indication: [Why prescribed]
   • Duration: [If limited duration]
   • Special instructions: [With food, time of day, etc.]

Changed Medications (Dose or Frequency Modified)

2. [Medication name] [NEW dose] [route] [frequency]
   • CHANGED FROM: [Previous dose and frequency]
   • Reason for change: [Why modified]

Continued Medications (No change from home medications)

3. [Medication name] [dose] [route] [frequency]
   • CONTINUED from home regimen

Discontinued Medications (Stopped During Hospitalization)

4. [Medication name] - DISCONTINUED
   • Reason: [Why stopped]

Complete Medication List for Patient

[Consolidated list in simple format for patient]

1. Furosemide 40 mg by mouth once daily [NEW - for fluid management]
2. Carvedilol 12.5 mg by mouth twice daily [CONTINUED]
3. Lisinopril 20 mg by mouth once daily [CONTINUED]
4. Metformin 1000 mg by mouth twice daily [CONTINUED]
5. Aspirin 81 mg by mouth once daily [CONTINUED]

Discharge Condition

Overall Status: [Stable / Improved / Baseline / Requires continued care]

Specific Assessments:

• Hemodynamic status: [Stable]
• Respiratory status: [Room air / Oxygen requirement]
• Mental status: [Alert and oriented x3 / Other]
• Functional status: [Ambulatory / Requires assistance / Bedbound]
• Pain control: [Adequate / Inadequate]
• Wound healing (if applicable): [Appropriate / Delayed]

Example:

Patient is hemodynamically stable, ambulatory without assistance, no supplemental 
oxygen requirement, euvolemic on physical exam, pain well-controlled, and has 
returned to baseline functional status.

Discharge Disposition

[Where patient is going after hospital discharge]

Options:

• Home with self-care
• Home with home health services
• Skilled nursing facility
• Acute rehabilitation facility
• Long-term acute care hospital
• Hospice (home or facility)
• Left against medical advice (AMA)
• Transferred to another acute care facility

Discharge Disposition: [Selection from above]

Services Arranged:

• Home health nursing
• Physical therapy
• Occupational therapy
• Durable medical equipment: [List items]
• Home oxygen: [Flow rate and delivery method]
• Other: [Specify]

Follow-Up Appointments

1. [Specialty/PCP] with Dr. [Name]

   • Date/Time: [Scheduled date and time] OR [Within X days/weeks]
   • Location: [Clinic name and address]
   • Phone: [Contact number]
   • Purpose: [What needs to be addressed]

2. [Additional appointments]

Pending Studies/Labs at Discharge

• [Test name]: [When due, where to go, reason]
• Results will be sent to: [Provider name]

Referrals Placed

• [Specialty]: [Reason for referral, contact information]

Patient Instructions

Activity

• [Specific activity restrictions or recommendations]
• Example: "Resume normal activities as tolerated. Avoid heavy lifting >10 lbs for 2 weeks."

Diet

• [Dietary restrictions or recommendations]
• Example: "Low sodium diet (less than 2 grams per day). Fluid restriction to 2 liters per day."

Wound Care (if applicable)

• [Incision care instructions]
• [Dressing change frequency]
• [When stitches/staples should be removed]

Self-Monitoring

• [What patient should monitor at home]
• Example: "Weigh yourself every morning. Call doctor if weight gain >2 lbs in 1 day or >5 lbs in 1 week."

Equipment/Supplies

• [Equipment provided or prescribed]
• [How to use]

Medications

• [General medication instructions]
• [Importance of compliance]
• [What to do if dose missed]

Return Precautions / Warning Signs

Call your doctor or return to emergency department if you experience:

• [Specific warning signs relevant to condition]
• [When to seek immediate care vs. call doctor]

Example for heart failure:

- Worsening shortness of breath or difficulty breathing
- Chest pain or pressure
- Severe swelling in legs or abdomen
- Weight gain more than 2 lbs in one day or 5 lbs in one week
- Dizziness, lightheadedness, or fainting
- Fever >101°F
- Any other concerning symptoms

Emergency Contact Numbers:

• Primary care physician: [Phone]
• Specialty clinic: [Phone]
• After-hours nurse line: [Phone]
• 911 for emergencies

Patient Education Provided

Topics discussed with patient and/or family:

• Disease process and prognosis
• Medication purpose, dosing, and side effects
• Warning signs and when to seek care
• Activity and dietary restrictions
• Follow-up appointments
• Use of medical equipment
• [Other specific topics]

Patient/Family Understanding: [Patient and family verbalize understanding of discharge instructions / Teach-back method used and patient able to repeat key points / Interpreter used]

Written Materials Provided:

• Discharge instructions
• Medication list
• Disease-specific education materials
• Emergency contact information
• Appointment information

Code Status at Discharge

Code Status: [Full code / DNR / DNI / Other limitations]

[If changed during hospitalization, note when and why]

Additional Information

Advance Directives

• Advance directive on file
• Healthcare proxy designated: [Name and contact]
• Living will present

Social Situation

[Relevant social factors affecting discharge plan]

• Living situation: [Lives alone / with family / assisted living]
• Caregiver support: [Available / Limited / None]
• Transportation: [Adequate / Needs assistance]
• Barriers to compliance: [Financial / Cognitive / Language / Other]

Pending Issues at Discharge

[Tests or consultations still pending that require outpatient follow-up]

Signature

Prepared by:
[Physician name, credentials]
[Pager/Contact number]

Cosigned by (if resident/fellow):
[Attending physician name]

Date and Time: [MM/DD/YYYY at HH:MM]

Electronically signed: [Yes/No]

Template Completion Checklist

• All discharge diagnoses listed with ICD-10 codes
• Hospital course summarized clearly
• All procedures documented
• Discharge medications reconciled and clearly marked (new/changed/continued/stopped)
• Follow-up appointments scheduled or timeframe provided
• Patient education documented
• Return precautions specific to patient's conditions
• Pending tests/results documented with follow-up plan
• Code status documented
• Completed within 24-48 hours of discharge (institutional requirement)
• Sent to primary care physician and relevant specialists
• Copy provided to patient

Notes

Timing Requirements:

• CMS requires completion within 30 days
• Many hospitals require 24-48 hours
• Should be available for follow-up appointments

Distribution:

• Send to primary care physician
• Send to referring physician
• Send to consulting specialists involved in care
• Provide copy to patient
• Upload to shared HIE (Health Information Exchange)

Quality Measures:

• Medication reconciliation required
• Clear communication of changes
• Specific follow-up plans
• Patient education documented