Discharge summary

A discharge summary is an account of the major events of the hospital admission for the patient’s GP, so that they can take over the patient’s care.

Introduction

  • Patient
    • Name
    • Hospital and NHS number
    • DOB
    • Address
    • GP details
  • Hospital stay
    • Consultant
    • Ward and hospital
    • Admission and discharge date
    • Discharge destination
  • Summary details
    • Date written
    • Your name and signature

Clinical details

  • Presentation
    • History
    • Examination
  • Investigations
    • Important investigation results
    • Any awaited results
  • Diagnosis and patient’s comorbidities 
  • Management 
    • How the patient was managed/treated
    • Response/complications

Future management

  • Management plans for after discharge
  • Follow-up appointment
  • Actions for GP

Medications

  • Regular medication changes
  • Medications to take home (medication, strength, form, directions, quantity)
    • Regular medications
    • Any added medications
    • Any PRN medications still being used (e.g. analgesia, antiemetics)

NB: out-patient controlled drug prescriptions must be handwritten and must include patient name and address; drug, strength and formulation; dose and frequency. The total quantity must be spelled out as well as written numerically.

Here’s some questions for you

Who is responsible for following up outstanding results after the patient is discharged?

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Should the discharge summary be written in medical or lay language?

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Can you write a discharge summary for a patient if you were not involved in their care?

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