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.