As medical professionals, we spend a lot of time focusing on the beginning of a patient’s journey with us: the admission note, the history and physical, the initial orders. But the end of that journey, the discharge, is just as critical. The document we create at that moment, the discharge summary, is more than just a form to fill out. It’s the final chapter of the patient’s hospital story and the first chapter of their next one at home or in another facility.

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Think of a discharge summary as a detailed handoff. You are handing the patient’s care back to their primary care provider (PCP), a specialist, a nursing home, or even the patient and their family themselves. If this handoff is unclear or incomplete, the patient’s recovery can be put at risk.

In this blog, you will learn how to write excellent discharge summaries. We’ll break down every section of the discharge note, explain why it matters, and provide examples. Whether you are a resident fresh on the wards, a nurse practitioner, a hospitalist, or a case manager, this information will help you create a document that is accurate, useful, and safe.

Let’s dive in and make sure our patients’ stories have a clear and helpful ending.

What is a Discharge Summary? (And Why It’s So Important)

A discharge summary is a vital medical document that is written when a patient is being released from a hospital or healthcare facility. It’s a comprehensive record of the patient’s entire admission. It explains why they came in, what we found, what we did for them, and most importantly, what happens next.

Why is this piece of paper (or electronic record) so important? First, it’s the main way we communicate with the doctors and nurses who will take over the patient’s care. Their family doctor needs to know exactly what happened in the hospital to continue treatment effectively. Second, it’s a safety tool. A good summary clearly lists new medications, follow-up appointments, and warning signs to watch for, which helps prevent the patient from ending up back in the hospital. Finally, it’s a legal document. It provides a clear, professional record of the care provided during the hospital stay.

For us, the writers, it’s a chance to show our clinical reasoning and summarize a complex story into a clear and concise plan. A well-written summary is a sign of a thoughtful and thorough clinician.

The Key Ingredients: What Every Discharge Summary Must Include

Before we write, we need to know what goes into the document. Most electronic health records (EHRs) have a template, but it’s our job to fill it out completely and thoughtfully. Here are the essential parts of a standard discharge summary, which we will explore in detail.

• Patient Demographics
• Admission and Discharge Dates
• Admission Diagnosis
• Discharge Diagnosis
• Consulting Physicians
• Brief History and Hospital Course
• Discharge Condition
• Discharge Disposition
• Discharge Medications
• Follow-Up Appointments
• Pending Results
• Discharge Instructions for the Patient

Let’s go through each one, step by step.

1. The Basics: Patient Info and Dates

This section might seem simple, but it’s the foundation. If this information is wrong, the whole document can be linked to the wrong person. This section includes:

• Patient’s Full Name
• Date of Birth
• Medical Record Number (MRN)
• Attending Physician
• Admission Date: (e.g., 10/15/2024)
• Discharge Date: (e.g., 10/18/2024)

Example:

Patient: Jane Doe
DOB: 05/12/1980
MRN: 88776655
Admitted: 10/15/2024
Discharged: 10/18/2024
Attending: Dr. John Smith

This data ensures the summary gets to the correct patient’s chart and is easily found by their future providers.

2. The “Why”: Admission and Discharge Diagnoses

This is where we state the reason for the hospital stay. The Admission Diagnosis is what we thought the patient had when they came through the door. The Discharge Diagnosis is what we finally determined the problem to be after all our tests and consults. Sometimes they are the same, and sometimes they change.

It is best practice to list the primary diagnosis first, followed by any secondary or chronic conditions that were also managed during the stay.

Example:

Admission Diagnosis:

1. Shortness of breath, suspected pneumonia.

Discharge Diagnosis:

1. Community-Acquired Pneumonia, Left Lower Lobe.
2. Acute Hypoxic Respiratory Failure.
3. Type 2 Diabetes Mellitus.
4. Essential Hypertension.

See how the discharge diagnosis is more specific? It tells the story of what we found. Listing the other conditions (Diabetes, Hypertension) reminds the outpatient doctor that these still need ongoing management.

3. The Story: Brief History and Hospital Course

This is the heart of the discharge summary. It’s a short story about the patient’s time in the hospital. You need to be detailed but concise. Think of it as telling another doctor what happened, from start to finish, in just a few paragraphs.

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Start with a one-sentence summary of the patient. Then, describe what happened when they arrived: their main symptoms, vital signs, and key physical exam findings. Next, list the important tests you did and their results. Finally, explain the treatment you provided and how the patient responded.

Bad Example:

“Patient came in with pneumonia. Was given antibiotics and got better.”

This is too vague and not helpful.

Good Example:

“Mrs. Doe is a 44-year-old female with a history of asthma who presented to the ER with 3 days of worsening productive cough, fever, and shortness of breath. On admission, she was febrile to 101.5°F, hypoxic with O2 sat 88% on room air, and had crackles in the left lower lobe on lung exam. A chest X-ray confirmed a left lower lobe infiltrate, consistent with community-acquired pneumonia. Labs showed an elevated WBC of 15k.

She was admitted and started on intravenous Ceftriaxone and Azithromycin for coverage of community-acquired pneumonia. She required 2 liters of oxygen via nasal cannula to maintain O2 sat >92% for the first 24 hours. She defervesced within 48 hours and her white blood cell count normalized. Her respiratory status improved steadily, and she was weaned off supplemental oxygen by hospital day 3. She remained hemodynamically stable throughout her stay. Infectious disease was consulted and recommended a total of 7 days of antibiotics. By the day of discharge, she was ambulating without SOB and afebrile.”

This “good example” tells a complete story. It includes the presentation, the workup, the treatment, the consultants, and the patient’s response. This is exactly what a PCP needs to know.

4. The “How”: Discharge Condition

This is a brief, objective description of the patient’s status at the exact moment they leave the hospital. It’s a snapshot of their health. Include their vital signs and a brief statement on their main symptoms.

Example:

Discharge Condition: Stable.
Vitals: Afebrile. Blood pressure 128/78. Heart rate 78. Respiratory rate 16. O2 saturation 98% on room air.
Exam: Lungs are clear to auscultation bilaterally. No respiratory distress. Heart regular rate and rhythm.

This tells the next provider, “The problem we treated is resolved, and the patient is in good shape to go home.”

5. The “Where”: Discharge Disposition

This simply states where the patient is going after they leave the hospital. This is very important for coordination of care.

Common dispositions:

• Home (with or without home health services)
• Skilled Nursing Facility (SNF) or Nursing Home
• Rehabilitation Facility (Inpatient Rehab)
• Transfer to another hospital

Example:

Discharge Disposition: Home with Home Health Care for skilled nursing visits and physical therapy.

6. The Plan: Discharge Medications

This is arguably one of the most important safety sections. Medication errors are a leading cause of hospital readmissions. You must be extremely clear here. Do not just copy and paste a list from the pharmacy. Create a clean, organized list.

You should present the medications in a clear way. A table is often easiest to read.

Example:

Medication Name	Dose	Route	Frequency	Duration/Notes
Amoxicillin	875 mg	By mouth	Twice daily	Take until 10/22/2024 (7 days total)
Albuterol HFA	90 mcg	Inhaled	Every 4-6 hours as needed	For wheezing or shortness of breath
Metformin	500 mg	By mouth	Twice daily with meals	For diabetes. Hold if you are very sick or dehydrated.
Lisinopril	10 mg	By mouth	Once daily	For blood pressure.

Make sure to:

• List new medications first, or clearly mark them.
• List medications that were stopped and why (e.g., “Stopped previous blood pressure medication, Amlodipine, due to leg swelling. Switched to Lisinopril.”)
• Clearly state which pre-admission medications the patient should resume and at what dose.

7. The Road Ahead: Follow-Up Appointments

Patients don’t get better just because they leave the hospital. They need ongoing care. You must arrange and clearly list follow-up appointments. Whenever possible, give a specific date and time, or at least a clear timeframe.

Example:

Follow-Up Appointments:

1. Primary Care Provider (Dr. Adams): Appointment scheduled for 10/25/2024 at 10:00 AM. Please bring your discharge summary to this visit.
2. Pulmonology (Dr. Lee): Please call 555-123-4567 to schedule an appointment within the next 2 weeks.
3. Repeat Chest X-ray: Scheduled for 10/30/2024 at 9:00 AM at Outpatient Radiology to ensure pneumonia has fully cleared.

8. Loose Ends: Pending Results

Sometimes, tests like lab cultures or pathology reports take days or weeks to come back. The patient may be discharged before the final result is known. You must list these pending tests and, crucially, state who is responsible for following up on them.

Never leave a pending result without an owner. The default should be the hospital team, the patient’s PCP, or a specific specialist.

Example:

Pending Results:

1. Sputum Culture: Sent 10/16/2024. Results pending 5-7 days.
   • Follow-up: Dr. Adams (PCP) will check these results in our electronic system and manage accordingly.
2. COVID-19 PCR Test: Sent 10/18/2024. Results expected within 24 hours.
   • Follow-up: Patient will be called directly by the hospital’s infection control team with results.

9. The Patient’s Copy: Discharge Instructions

The last section is for the patient and their family. It must be written in plain language, avoiding medical jargon. Think 9th-grade reading level. This is the take-home guide they will refer to when they have questions at 2 AM.

This section should include:

• Diagnosis in simple terms: “You were treated for pneumonia, which is an infection in your lungs.”
• Medication instructions: A simpler version of the medication list.
• Activity: “You may resume your normal activities as tolerated. Get plenty of rest.”
• Diet: “No special diet. Continue with heart-healthy, low-salt choices for your blood pressure.”
• Warning Signs (When to call the doctor or 911): This is critical. Be specific.

Example of Warning Signs:

When to Call Your Doctor:

• Fever of 100.4°F or higher.
• Shortness of breath that is getting worse.
• Coughing up blood.
• Not being able to keep food or medicine down.

When to Go to the Emergency Room or Call 911:

• Severe trouble breathing.
• Chest pain.
• Confusion or passing out.

Examples

Let’s put it all together with three different scenarios.

Example 1: Uncomplicated Pneumonia (The one we’ve been building)

• Patient: Jane Doe
• DOB: 05/12/1980
• Admission Date: 10/15/2024
• Discharge Date: 10/18/2024
• Admission Diagnosis: Shortness of breath, suspected pneumonia.
• Discharge Diagnosis: Community-Acquired Pneumonia, Left Lower Lobe.
• Brief Hospital Course: (Use the “good example” text from Section 3)
• Discharge Condition: Stable, afebrile, vital signs normal. Ambulating without difficulty.
• Discharge Disposition: Home with Home Health.
• Discharge Medications: (Use the table from Section 6)
• Follow-Up: PCP Dr. Adams on 10/25. Pulmonology Dr. Lee in 2 weeks.
• Pending Results: Sputum culture, follow-up with Dr. Adams.
• Patient Instructions: (Use the plain language instructions from Section 9)

Example 2: Patient Going to a Skilled Nursing Facility (SNF)

• Patient: Robert Jones
• DOB: 02/28/1945
• Admission Date: 10/10/2024
• Discharge Date: 10/20/2024
• Admission Diagnosis: Left hip pain after a fall.
• Discharge Diagnosis: Left femoral neck fracture, status post hip replacement.
• Brief Hospital Course: Mr. Jones is a 79-year-old male who fell at home, resulting in a left femoral neck fracture. He underwent an uncomplicated left total hip arthroplasty on 10/11/2024 by Dr. White. Post-operatively, his pain was well-controlled with oral analgesics. Physical therapy worked with him daily. He made good progress but still requires significant assistance with transfers and ambulation due to baseline deconditioning. He is medically stable for discharge.
• Discharge Condition: Stable. Alert and oriented. Surgical incision is clean, dry, and intact. Pain is controlled.
• Discharge Disposition: Transition to “Shady Pines Skilled Nursing Facility” for continued physical therapy and rehabilitation.
• Discharge Medications:
  • Oxycodone 5 mg, take 1-2 tablets by mouth every 4-6 hours as needed for severe pain.
  • Aspirin 81 mg, one tablet by mouth once daily for DVT prophylaxis.
  • Senna 8.6 mg, one tablet by mouth twice daily as needed for constipation.
• Follow-Up: With Dr. White (Orthopedics) in 2 weeks at his clinic. Appointment to be scheduled by the SNF.
• Pending Results: None.
• Patient Instructions (for SNF staff and family): Follow hip precautions: no bending past 90 degrees, no crossing legs, use an elevated toilet seat. Keep the surgical incision dry until the follow-up appointment.

Example 3: Exacerbation of a Chronic Condition (Heart Failure)

• Patient: Maria Garcia
• DOB: 11/03/1960
• Admission Date: 10/12/2024
• Discharge Date: 10/17/2024
• Admission Diagnosis: Worsening shortness of breath and leg swelling.
• Discharge Diagnosis: Acute on Chronic Diastolic Heart Failure, exacerbation likely due to dietary non-compliance.
• Brief Hospital Course: Ms. Garcia is a 63-year-old female with a known history of heart failure who presented with 5 days of progressive dyspnea on exertion, orthopnea, and 2+ pitting edema in her bilateral lower extremities. In the ER, she was hypertensive to 180/95, and a chest X-ray showed pulmonary vascular congestion. Labs revealed an elevated BNP of 1200. She was admitted and aggressively diuresed with IV Furosemide. She lost 8 kg of fluid weight over 5 days. Her oxygen saturation improved, and her edema resolved. She was transitioned to oral Lasix. She received teaching from the dietitian on a 2-gram sodium diet and from nursing on daily weight monitoring.
• Discharge Condition: Stable. Vital signs are stable. Lungs clear. No edema.
• Discharge Disposition: Home.
• Discharge Medications:
  • Furosemide (Lasix) 40 mg, one tablet by mouth twice daily. (NEW DOSE)
  • Lisinopril 20 mg, one tablet by mouth once daily.
  • Metoprolol Succinate 50 mg, one tablet by mouth once daily.
• Follow-Up: With Cardiologist Dr. Patel on 10/24/2024 at 11:30 AM.
• Pending Results: None.
• Patient Instructions:
  • Medicines: Take all your medicines exactly as prescribed. Do not skip your water pill (Lasix).
  • Diet: Follow a low-salt (2 gram sodium) diet. Do not add salt to your food.
  • Daily Weighing: Weigh yourself every morning, after you urinate but before you eat or drink. Write it down.
  • Call your doctor if:
    • You gain 3 or more pounds in one day, or 5 pounds in a week.
    • You have more shortness of breath than usual.
    • You have new swelling in your legs or ankles.

Common Mistakes and How to Avoid Them

Even experienced clinicians can make errors. Here are some common pitfalls and how to steer clear of them.

• The “Copy and Paste” Trap: EHRs make it easy to copy notes forward. This is dangerous. Always review every section for accuracy. A patient’s history from a previous admission may no longer be relevant. Old medications might be listed. Treat every discharge summary as a new, unique document.
• Vague Follow-Up Plans: Telling a patient to “follow up soon” is not a plan. It’s a setup for failure. Whenever possible, give a specific date, time, and provider’s name. If a date isn’t set, give a clear phone number and timeframe.
• Forgetting the “Owner” of Pending Tests: This is a major patient safety issue. A biopsy result comes back positive a week after discharge, and no one is responsible for telling the patient. Always, always, always state who will handle the result.
• Medication List Discrepancies: The list of meds given to the patient, the list in the discharge summary, and the list sent to the pharmacy must all be identical. Conflicting lists cause confusion and dangerous medication errors. Double-check your work.
• Using Jargon in Patient Instructions: Never tell a patient to “follow up for a PT/INR.” Tell them they need “a blood test to check their blood thinner levels.” Keep it simple.

Final Thoughts: The Power of a Good Summary

Writing a discharge summary can sometimes feel like a chore at the end of a long shift. But I encourage you to see it differently. See it as the final, crucial act of care for your patient.

A strong discharge summary protects your patient. It empowers their next provider. It reduces the chance of them being readmitted. And it serves as a clear, professional record of the work you did. It’s a testament to your thoroughness and your commitment to patient safety from the moment they arrive to the moment they walk out the door.

Take your time with it. Make it clear, complete, and compassionate. Your patients and your colleagues will thank you for it.

Thank you for the hard work you do every day.

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