Discharge Summary Template

What Is a Discharge Summary?

A discharge summary is a clinical document written at the end of a hospital stay that communicates everything the next provider needs to know: why the patient was admitted, what happened during hospitalization, what the patient is going home with, and what needs to happen next. It is the single most important handoff document in medicine.

The Joint Commission requires a discharge summary for every inpatient stay, and CMS ties timely completion to hospital quality metrics. Beyond compliance, a well-written discharge summary prevents readmissions, reduces medication errors at transitions of care, and gives the outpatient provider a clear picture of what occurred.

Who Uses This Template?

• Hospitalists writing summaries at the end of inpatient stays
• Residents responsible for discharge documentation on teaching services
• Intensivists summarizing ICU stays and step-down transitions
• Surgeons documenting postoperative hospital courses
• Care coordinators using the summary for transitional care planning

Template

Patient Demographics

• Patient name, date of birth, medical record number
• Admission date and discharge date
• Length of stay
• Attending physician
• Primary care physician (for outpatient follow-up coordination)

Admission Diagnoses

List the diagnoses that justified the admission. Use ICD-10 codes when your system requires them.

• Example: "1. Community-acquired pneumonia (J18.9)"
• Example: "2. Acute hypoxemic respiratory failure (J96.01)"
• Example: "3. Type 2 diabetes mellitus, uncontrolled (E11.65)"

Discharge Diagnoses

List the final diagnoses at discharge. These may differ from admission diagnoses as workup reveals new information.

• Example: "1. Community-acquired pneumonia, Streptococcus pneumoniae (J13)"
• Example: "2. Acute hypoxemic respiratory failure, resolved (J96.01)"
• Example: "3. Type 2 diabetes mellitus with hyperglycemia (E11.65)"
• Example: "4. Newly diagnosed iron-deficiency anemia (D50.9)"

Procedures Performed

Document all significant procedures during the hospitalization.

• Example: "CT chest with contrast (02/15/2026)"
• Example: "Bronchoscopy with bronchoalveolar lavage (02/16/2026)"
• Example: "PICC line placement, right basilic vein (02/16/2026)"

Brief Hospital Course

This is the narrative heart of the discharge summary. Organize it by problem, and for each problem describe the clinical trajectory from admission to discharge.

Community-acquired pneumonia: "Patient presented to the ED with three days of productive cough, fever to 102.8 F, and progressive dyspnea. CXR showed right lower lobe consolidation. Blood cultures grew Streptococcus pneumoniae. Started on ceftriaxone 1 g IV daily and azithromycin 500 mg IV daily on hospital day 1. Fever curve trended down by day 2. Transitioned to oral amoxicillin-clavulanate 875/125 mg BID on day 4 after tolerating oral intake and remaining afebrile for 48 hours. Repeat CXR on day 5 showed improving consolidation."

Acute hypoxemic respiratory failure: "Required 4 L/min supplemental oxygen via nasal cannula on admission with SpO2 88% on room air. Oxygen requirements gradually decreased. Weaned to room air on hospital day 4 with SpO2 94–96% at rest and with ambulation."

Type 2 diabetes mellitus: "Home metformin held on admission. Managed with insulin sliding scale. Blood glucose ranged 180–280 mg/dL in the first 48 hours, improved to 120–180 mg/dL by day 3. HbA1c obtained: 9.2%, indicating poor outpatient control. Metformin resumed at discharge. Added glipizide 5 mg daily. Diabetes education provided by inpatient educator."

Iron-deficiency anemia (new diagnosis): "Hemoglobin 9.8 g/dL on admission labs. Iron studies consistent with iron-deficiency anemia: ferritin 12 ng/mL, TIBC 420 mcg/dL, iron saturation 8%. Patient reports no melena, hematochezia, or heavy menses. Started on ferrous sulfate 325 mg daily. Outpatient colonoscopy recommended given age and new iron-deficiency anemia."

Discharge Condition

• Example: "Stable. Ambulating independently. Tolerating regular diet. Afebrile for 72 hours. Room air SpO2 95%."

Discharge Medications

List every medication the patient is being discharged with, including dosage, route, and frequency. Flag changes from the preadmission medication list.

• Amoxicillin-clavulanate 875/125 mg PO BID x 6 more days (NEW — to complete antibiotic course)
• Metformin 1000 mg PO BID (RESUMED — held during admission)
• Glipizide 5 mg PO daily (NEW)
• Ferrous sulfate 325 mg PO daily (NEW)
• Lisinopril 10 mg PO daily (unchanged)
• Atorvastatin 20 mg PO daily (unchanged)
• Aspirin 81 mg PO daily (unchanged)

Medications Discontinued

• Insulin sliding scale (discontinued — inpatient only)
• Ceftriaxone IV (completed — transitioned to oral)
• Azithromycin IV (completed)

Allergies

• Sulfa drugs — anaphylaxis

Follow-Up Appointments

Provide specific dates and provider names whenever possible.

• PCP (Dr. Martinez): Within 7 days of discharge for BP check, glucose review, and antibiotic completion
• Pulmonology (Dr. Chen): 4–6 weeks for repeat CXR and post-pneumonia follow-up
• Gastroenterology: Outpatient colonoscopy — referral placed, office will contact patient to schedule

Pending Results at Discharge

Clearly document any results that were not yet available.

• Sputum culture sensitivities — final results pending
• Stool occult blood x 3 — patient given cards, to return to PCP

Patient Education and Instructions

• Complete full course of antibiotics. Do not stop early even if feeling better.
• Monitor blood glucose at home: fasting AM and 2 hours post-dinner. Log and bring to PCP visit.
• Take iron supplement on an empty stomach with vitamin C to improve absorption. Expect dark stools.
• Return to ED if: fever above 101.5 F, worsening shortness of breath, chest pain, coughing up blood, or blood glucose above 400 mg/dL.

Disposition

• Discharged to: Home
• Activity level: Resume normal activity as tolerated. Avoid strenuous exercise for one week.
• Diet: Diabetic diet. Increase iron-rich foods (red meat, spinach, lentils).
• DME: None required.

Common Mistakes in Discharge Summaries

1. Delayed completion — A discharge summary that arrives two weeks after discharge is useless for the outpatient follow-up that already happened. Aim for completion within 24–48 hours.
2. Missing medication reconciliation — Failing to clearly mark which medications are new, changed, resumed, or discontinued leads to errors at transitions of care. This is the number-one cause of post-discharge adverse drug events.
3. Vague hospital course — "Treated with antibiotics and improved" does not help the next provider. Name the antibiotics, the duration, the culture results, and the clinical response.
4. No pending results — If the PCP does not know sputum cultures are pending, no one follows up on them. Every pending result must be documented and assigned to a responsible provider.
5. Missing follow-up specifics — "Follow up with PCP" without a timeframe or reason is insufficient. State the purpose and urgency of each follow-up.

Tips for Faster, Better Discharge Summaries

• Start drafting early. Begin the summary on the day of admission and update it throughout the hospital stay rather than writing the entire document at discharge.
• Use a problem-based hospital course. Organizing by problem rather than chronologically makes the summary far easier for the outpatient provider to navigate.
• Reconcile medications systematically. Walk through the preadmission list line by line. Mark each as continued, held, changed, or discontinued.
• Dictate when possible. Dictation captures the hospital course faster than typing and reduces after-hours documentation burden.

Automate Your Discharge Summaries

Writing discharge summaries from scratch on high-census days leads to delays, omissions, and physician burnout. NotuDocs can draft discharge summaries from your clinical data, organizing the hospital course by problem and flagging medication changes — so you review, refine, and sign instead of starting from a blank screen.