Discharge Summary From Hospital Notes

In the US, Medicare's rules for hospitals set only a floor. They require a discharge summary with the outcome of hospitalization, disposition of the case and provisions for follow-up care¹, and a complete record within 30 days of discharge. Your hospital's template and medical staff rules set the rest.

Six medical societies, including the American College of Physicians and the Society of Hospital Medicine, set out the minimum every transition record should carry² in a 2009 consensus statement. It covers the principal diagnosis and problem list, a reconciled medication list with allergies, the clinician to contact, the patient's cognitive status, and test results, including pending ones.

Work from the chart, not from memory. Before you start, gather everything the summary draws on:

• The history and physical, consult and procedure notes, and the latest progress note
• The home medication list beside the discharge orders
• Results, including tests sent but not yet back
• Nursing and therapy notes on mobility, diet and skin
• Case management notes on where the patient is going
• Code status and any goals of care discussion

Don't copy the last progress note into the summary. Its daily detail buries what changed, and copied text carries forward problems that resolved days ago. Daily notes in a consistent SOAP format make this step faster, because each day's assessment and plan sit in the same place.

The hospital course is where summaries sprawl. For a short, simple stay, a few sentences in order of events are enough. For a long or complicated one, go problem by problem, starting with the principal diagnosis.

For each problem, answer four questions in two or three sentences: what it was, what you did, where it stands, and what happens next. For example: "Acute on chronic systolic heart failure. Admitted 5 kg above dry weight and diuresed with IV furosemide, net loss 4 kg; now comfortable on room air. Home on a higher furosemide dose, weighing daily."

Leave out daily vital signs and normal results unless they changed a decision. Then describe the patient on the day they left, since the next team plans around it: mobility, mental status against baseline, oxygen and diet.

Drug problems are among the most common harms after discharge. In a 2003 study of 400 patients sent home from a general medical service, 19% had an adverse event within about 3 weeks of leaving³. Two-thirds of the events were drug-related.

So write the list as a comparison with what the patient took before admission. The federal Agency for Healthcare Research and Quality describes medication reconciliation⁴ as comparing the patient's complete regimen with the one planned for the next setting. Its aim is to catch needed drugs left off, needless duplicates and wrong doses.

Sort every drug into started, changed, stopped or continued. Give the old and new dose for each change, and a reason for every start, change and stop. Write doses and frequencies in full, so a nurse at another facility reads them as you meant. For a long or high-risk list, reconcile it with a pharmacist.

Results that arrive after the patient has gone are easy to lose. A 2005 study of 2,644 patients discharged from hospitalist services at two academic hospitals found 41% had test results come back after they left⁵. Survey replies on 105 potentially actionable results showed physicians had been unaware of 62%. Summaries often omit them: a 2007 systematic review in JAMA reported pending results missing from 65% of discharge summaries⁶.

List each pending test with what it is, when it was sent, who will follow it up and how the patient will hear. Name a person or a role, such as the discharging hospitalist, not just "the team." If nothing is pending, write "None" so the reader knows you checked.

A primary care doctor needs the actions up front: what to check, adjust or stop, and by when. A nursing facility also needs mobility, diet, skin and wound care, lines, code status, and when the last dose of each time-critical drug was given.

The same JAMA review found a discharge summary was available at the first follow-up visit in only 12% to 34% of cases⁶. Medicare's discharge planning rule requires hospitals to send necessary medical information to the clinicians and facilities responsible for follow-up care, at the time of discharge⁷. Aim to finish the summary before the patient leaves.

If the patient needs a specialist next, a referral letter carries the clinical question forward. Give the patient their own instructions in plain words, without abbreviations; a patient education handout can explain the condition itself.

For a first draft from your own notes, paste them into the tool at the top of this page. It drafts every part covered here and brackets whatever your notes leave out.