Table of Contents
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.