Hospital discharge summary template

Hospital Discharge Summary

Admission Details
- Date of admission and discharge; admitting service; discharging clinician.
- Admission chief complaint / reason for hospitalization.

Hospital Course
- Concise narrative of presentation, key findings, treatments, complications, and response.
- Major diagnostics and procedures with results.
- Consultant involvement and salient recommendations.

Final Diagnoses
- Primary discharge diagnosis and secondary diagnoses (active and relevant chronic).

Procedures
- Procedures/operations performed during admission with dates.

Condition at Discharge
- Clinical status, ambulatory status, diet, oxygen requirement, wound/drain status, and cognitive status as relevant.
- Code status at discharge.

Discharge Medications
- Medication reconciliation: new, changed, stopped, and continued medications with doses.
- High-risk med counseling (anticoagulation, insulin, opioids, steroids) as discussed.
- Allergies confirmed.

Pending Results
- Studies/labs pending at discharge and who will follow (clinic, ordering team, patient instructions).

Discharge Disposition & Instructions
- Disposition (home, SNF, rehab, AMA, etc.) and services arranged (home health, DME, oxygen).
- Activity, diet, wound care, and symptom monitoring instructions.
- Return precautions / when to seek emergency care.

Follow-Up
- PCP and specialty appointments with timing; scheduled vs to-be-scheduled.
- Post-discharge labs or INR checks if applicable.

Patient Education / Shared Understanding
- Teaching provided and patient/caregiver teach-back as documented.