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.
Hospital and NHS number
Ward and hospital
Admission and discharge date
Your name and signature
Important investigation results
Any awaited results
Diagnosis and patient’s comorbidities
How the patient was managed/treated
Management plans for after discharge
Actions for GP
Regular medication changes
Medications to take home (medication, strength, form, directions, quantity)
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?
Should the discharge summary be written in medical or lay language?
Can you write a discharge summary for a patient if you were not involved in their care?