How to Write a Discharge Summary

Why Discharge Summaries Matter More Than You Think

The discharge summary is the most consequential document in hospital medicine. It is the primary communication tool between the inpatient team and every provider who will see the patient afterward — the primary care physician scheduling a follow-up, the home health nurse visiting the next morning, the specialist reviewing the case weeks later, and the emergency physician if the patient bounces back. Strong discharge documentation complements the H&P documentation created at admission.

Studies consistently show that incomplete or delayed discharge summaries are associated with higher readmission rates, medication errors at transitions of care, and adverse events in the post-hospitalization period. A 2023 systematic review found that the availability of a discharge summary at the first outpatient follow-up visit reduced 30-day readmissions by nearly 20%.

Despite this, discharge summaries are one of the most frequently delayed and poorly written documents in medicine. This guide walks you through how to write one that actually serves its purpose.

When to Start Writing

The single most impactful habit you can adopt is to start writing the discharge summary on admission day. This is counterintuitive — the patient just arrived, and you do not yet know the full hospital course. But the demographics, admission diagnoses, past medical history, home medications, and allergies are all available on day one.

Create a skeleton on admission. Update it daily as the hospital course unfolds. By discharge day, you are editing a near-complete document rather than reconstructing a multi-day stay from memory.

Practical workflow:

• Day 1: Fill in demographics, admission diagnoses, PMH, medications, allergies
• Daily: Add one to two sentences to the hospital course for each active problem as significant events occur (culture results, medication changes, imaging findings, consultations)
• Discharge day: Complete the discharge medications, follow-up plan, pending results, and patient education sections. Review and finalize.

Essential Components, Step by Step

1. Admission and Discharge Diagnoses

List the admission diagnoses (what you thought on day one) and the discharge diagnoses (what you know at the end). These often differ, and the difference is clinically meaningful.

Common mistake: Listing only the primary diagnosis and forgetting secondary or newly discovered diagnoses. If you found iron-deficiency anemia incidentally during a pneumonia admission, it belongs in the discharge diagnoses.

Good example:

• Admission: Community-acquired pneumonia; acute hypoxemic respiratory failure
• Discharge: Community-acquired pneumonia (Streptococcus pneumoniae); acute hypoxemic respiratory failure, resolved; type 2 diabetes mellitus with hyperglycemia; iron-deficiency anemia, newly diagnosed

2. Hospital Course

This is the section where most discharge summaries fail. The two most common failure modes are writing too little ("treated with antibiotics, improved, now stable for discharge") and writing too much (a day-by-day copy of progress notes).

The right approach: problem-based narrative.

Organize the hospital course by problem, not by calendar day. For each problem, describe:

• How it presented
• What the workup showed
• What treatment was given (specific drugs, doses, durations)
• How the patient responded
• What the status is at discharge

Example:

"Community-acquired pneumonia: Presented with three days of productive cough, fever to 102.8 F, and progressive dyspnea. CXR on admission showed right lower lobe consolidation. Blood cultures on day 1 grew Streptococcus pneumoniae (pan-sensitive). Started on ceftriaxone 1 g IV daily and azithromycin 500 mg IV daily. Fever curve trended down by day 2 and resolved by day 3. Transitioned to oral amoxicillin-clavulanate 875/125 mg BID on day 4 after the patient tolerated oral intake and remained afebrile for 48 hours. To complete a total of 7 days of antibiotics (6 remaining days as outpatient)."

What makes this effective:

• Specific culture results, not just "cultures were sent"
• Named antibiotics with doses, not "IV antibiotics"
• Clear transition rationale
• Remaining course quantified for the outpatient provider

3. Medication Reconciliation

This is the single highest-risk section of the discharge summary. Medication errors at transitions of care cause an estimated 12% of all post-discharge adverse drug events.

Walk through the preadmission medication list line by line. For each medication, categorize it as:

• Continued (unchanged)
• Changed (dose adjusted — state old and new dose)
• Held (temporarily — state reason and when to resume)
• Discontinued (permanently — state reason)
• New (added during hospitalization — state indication)

Format the discharge medication list clearly:

• Metformin 1000 mg PO BID — RESUMED (held during admission)
• Glipizide 5 mg PO daily — NEW (added for uncontrolled diabetes, HbA1c 9.2%)
• Ferrous sulfate 325 mg PO daily — NEW (for iron-deficiency anemia)
• Amoxicillin-clavulanate 875/125 mg PO BID x 6 days — NEW (to complete antibiotic course)
• Lisinopril 10 mg PO daily — continued, unchanged
• Atorvastatin 20 mg PO daily — continued, unchanged

Common mistake: Listing the discharge medications without flagging changes. The outpatient provider cannot easily compare to the pre-admission list unless you explicitly mark what changed and why.

4. Pending Results

This is the most commonly omitted — and one of the most dangerous omissions — in a discharge summary. If a test was ordered but results were not available at discharge, someone must follow up on it. That responsibility must be explicitly assigned.

Format:

• Sputum culture final sensitivities — pending. Preliminary results consistent with ceftriaxone-sensitive Streptococcus pneumoniae. PCP to follow up on final result and adjust antibiotics if needed.
• Stool guaiac cards — given to patient, to return completed cards to PCP office.
• Pathology from bronchoscopy biopsy — pending. Pulmonology to follow and communicate results to PCP.

Rule of thumb: If the result could change management, it must be in the pending results section with a named responsible provider.

5. Follow-Up Plan

Vague follow-up instructions are nearly as dangerous as no follow-up at all. "Follow up with PCP" without a timeframe, a reason, or specific action items is insufficient.

Effective follow-up documentation includes:

• Who the patient should see
• When (specific timeframe, or ideally a scheduled date)
• Why (what needs to be addressed at that visit)
• What the outpatient provider should do

Example:

• PCP (Dr. Martinez): Within 7 days. Recheck BP (elevated during admission, may be pain-related vs. worsening hypertension), review blood glucose logs (new glipizide started), confirm antibiotic completion, follow up on pending sputum culture.
• Pulmonology (Dr. Chen): 4–6 weeks. Repeat CXR to confirm pneumonia resolution. Review bronchoscopy biopsy results.
• GI: Referral placed for outpatient colonoscopy given new iron-deficiency anemia in a patient over 50.

6. Patient Education and Contingency Instructions

Document what the patient was told, and what should prompt them to seek urgent care.

• Example: "Patient educated on completing full antibiotic course. Instructed to monitor blood glucose fasting and post-dinner, log results, and bring to PCP visit. Advised to return to ED for fever above 101.5 F, worsening dyspnea, chest pain, hemoptysis, or blood glucose above 400."

This section is not just patient-facing — it tells the outpatient provider what the patient was counseled about, which supports continuity of education.

Common Discharge Summary Pitfalls

The Copy-Paste Hospital Course

Copying daily progress notes into the hospital course section creates a lengthy, unstructured wall of text that no outpatient provider will read. The hospital course should be a synthesized narrative, not a chronological data dump. If your hospital course exceeds one page for a straightforward admission, it is probably too detailed.

The Missing Medication Reconciliation

The number one cause of post-discharge medication errors is failing to clearly communicate what changed. A list of discharge medications without context forces the PCP to compare line by line against the last known medication list — a process that introduces errors. Always flag changes explicitly.

The Delayed Summary

A discharge summary that arrives two weeks after discharge is clinically useless. The patient has already had their follow-up visit (or been readmitted). Target completion within 24 hours. If your institution requires attending cosignature, at minimum have the draft complete before the patient leaves the building.

Similar principles of timely documentation apply across all clinical disciplines. See documentation best practices for universal guidelines.

Omitting the "So What"

A discharge summary should not just record what happened — it should tell the next provider what to do about it. "HbA1c was 9.2%" is a fact. "HbA1c 9.2%, indicating poor outpatient glycemic control. Glipizide 5 mg daily started. Patient will need dose titration at PCP follow-up and possible addition of a second agent" is actionable.

Forgetting the Patient's Perspective

The discharge summary should note the patient's understanding of their condition, their adherence barriers, and their social context. "Patient lives alone and has difficulty affording medications" is critical information for the outpatient provider planning a treatment regimen.

Dictation Tips for Faster Summaries

If you dictate your summaries, organize your thoughts by problem before you start speaking. Have the chart open in front of you. Dictate the hospital course problem by problem rather than reading through daily notes chronologically.

A useful structure for dictation:

1. State the patient's name, MRN, and admission/discharge dates
2. List the discharge diagnoses
3. For each problem: present, work up, treat, result, status at discharge
4. Read the discharge medication list, flagging changes
5. State pending results with responsible providers
6. State follow-up plan
7. State discharge disposition and patient education provided

With practice, a straightforward discharge summary can be dictated in 5–8 minutes using this approach.

Quality Checklist

Before you sign a discharge summary, verify these elements:

• Admission and discharge diagnoses are both listed and accurate
• Hospital course covers every active problem with specific treatments and results
• Discharge medications are listed with changes flagged (new, changed, resumed, discontinued)
• Pending results are documented with responsible follow-up providers named
• Follow-up appointments include who, when, and why
• Patient education and return-to-ED criteria are documented
• Allergies are confirmed
• Discharge condition and disposition are stated

Automate the Process

Even with the best habits, discharge summaries consume significant physician time. NotuDocs drafts discharge summaries from your clinical data, organizing the hospital course by problem and flagging every medication change — so you review and refine instead of writing from a blank page on a high-census day.