Discharge summaries are essential documents that ensure continuity of care from hospital to outpatient settings. Let’s review how to create effective discharge summaries and create a standardized template to enhance documentation practices among healthcare professionals.
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A discharge summary is a comprehensive document detailing a patient’s hospital stay from admission to discharge. It outlines the reasons for admission, treatments administered, clinical outcomes, and specific plans for follow-up care.
Functionality
Crafted primarily by the attending physician, this document serves as a crucial communication tool for subsequent care providers, offering insights into the patient’s acute hospital course, aiding in ongoing care management, and anticipating potential health issues.
Characteristics of an Effective Discharge Summary
An effective discharge summary is succinct yet comprehensive, accurately reflecting the patient’s health status and treatment trajectory. Key elements include:
Clear, detailed, and specific summaries ensure seamless care transitions and help prevent clinical oversights.
Discharge summaries are vital for several reasons:
Effectively, these summaries not only streamline patient management but also contribute to improved health outcomes.
Implementing a discharge summary template offers numerous benefits:
Templates not only aid in maintaining high standards of clinical documentation but also ensure that all relevant details are communicated effectively to all subsequent care providers.
Below is a standardized discharge summary template and three examples. You can follow this template to ensure comprehensive documentation with enough context to aid in the communication between healthcare providers.
Name: [Insert name]
Admission Date: [Insert date]
Discharge Date: [Insert date]
Date of Birth: [Insert DOB]
Sex: [Insert sex]
History of Present Illness: [Detailed clinical presentation]
Past Medical History: [Comprehensive listing of relevant past medical conditions]
Past Diagnosis: [Relevant past diagnoses]
Brief Hospital Course: [Detailed account of the treatment provided and patient’s response]
Medications at Admission: [Detailed listing of medications and dosages at admission]
Discharge Medications: [Detailed listing of medications and dosages at discharge]
Follow-up Plans: [Specific plans for follow-up care, including appointments and therapeutic considerations]
Name: John Doe
Admission Date: January 1, 2024
Discharge Date: January 5, 2024
Date of Birth: July 7, 1990
Sex: Male
History of Present Illness: Presented with severe abdominal pain and vomiting.
Past Medical History: Type 2 diabetes.
Past Diagnosis: Gastroenteritis.
Brief Hospital Course: Treated with IV fluids and antibiotics. Symptoms improved steadily.
Medications at Admission: Metformin.
Discharge Medications: Metformin continued, new prescription for a proton pump inhibitor.
Follow-up Plans: Follow-up with a gastroenterologist in one week; monitor blood sugar levels regularly.
Name: Jane Smith
Admission Date: March 12, 2024
Discharge Date: March 18, 2024
Date of Birth: November 15, 1985
Sex: Female
History of Present Illness: Shortness of breath and chest pain.
Past Medical History: Hypertension.
Past Diagnosis: Asthma.
Brief Hospital Course: Diagnosed with pneumonia, treated with antibiotics and supplemental oxygen.
Medications at Admission: Lisinopril.
Discharge Medications: Lisinopril, new antibiotic course.
Follow-up Plans: Chest X-ray in two weeks; primary care follow-up within three days.
Name: Alice Johnson
Admission Date: May 10, 2024
Discharge Date: May 15, 2024
Date of Birth: January 22, 1970
Sex: Female
History of Present Illness: Sudden onset of severe headache and dizziness.
Past Medical History: None.
Past Diagnosis: Migraine.
Brief Hospital Course: Underwent MRI, results normal. Symptoms managed with medication.
Medications at Admission: None.
Discharge Medications: Prescription for sumatriptan.
Follow-up Plans: Neurology follow-up within one month; monitor symptoms and triggers.
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Name: [Insert name]
Admission Date: [Insert date]
Discharge Date: [Insert date]
Date of Birth: [Insert DOB]
Sex: [Insert sex]
History of Present Illness: [Detailed clinical presentation]
Past Medical History: [Comprehensive listing of relevant past medical conditions]
Past Diagnosis: [Relevant past diagnoses]
Brief Hospital Course: [Detailed account of the treatment provided and patient’s response]
Medications at Admission: [Detailed listing of medications and dosages at admission]
Discharge Medications: [Detailed listing of medications and dosages at discharge]
Follow-up Plans: [Specific plans for follow-up care, including appointments and therapeutic considerations]
Name: John Doe
Admission Date: January 1, 2024
Discharge Date: January 5, 2024
Date of Birth: July 7, 1990
Sex: Male
History of Present Illness: Presented with severe abdominal pain and vomiting.
Past Medical History: Type 2 diabetes.
Past Diagnosis: Gastroenteritis.
Brief Hospital Course: Treated with IV fluids and antibiotics. Symptoms improved steadily.
Medications at Admission: Metformin.
Discharge Medications: Metformin continued, new prescription for a proton pump inhibitor.
Follow-up Plans: Follow-up with a gastroenterologist in one week; monitor blood sugar levels regularly.
Name: Jane Smith
Admission Date: March 12, 2024
Discharge Date: March 18, 2024
Date of Birth: November 15, 1985
Sex: Female
History of Present Illness: Shortness of breath and chest pain.
Past Medical History: Hypertension.
Past Diagnosis: Asthma.
Brief Hospital Course: Diagnosed with pneumonia, treated with antibiotics and supplemental oxygen.
Medications at Admission: Lisinopril.
Discharge Medications: Lisinopril, new antibiotic course.
Follow-up Plans: Chest X-ray in two weeks; primary care follow-up within three days.
Name: Alice Johnson
Admission Date: May 10, 2024
Discharge Date: May 15, 2024
Date of Birth: January 22, 1970
Sex: Female
History of Present Illness: Sudden onset of severe headache and dizziness.
Past Medical History: None.
Past Diagnosis: Migraine.
Brief Hospital Course: Underwent MRI, results normal. Symptoms managed with medication.
Medications at Admission: None.
Discharge Medications: Prescription for sumatriptan.
Follow-up Plans: Neurology follow-up within one month; monitor symptoms and triggers.
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