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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
    • 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.

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