Discharge summary
Also called Discharge letter
A discharge summary tells the patient's primary care physician what happened in the hospital: diagnoses, treatment, medication changes and what needs follow-up.
Why it matters in a workup
The primary care physician acts on the discharge summary, often without other information. Medication changes and outstanding actions are the parts read most closely.
Write each action with an owner. Please recheck renal function in two weeks is clearer than renal function to be monitored.
Put it into practice
- List diagnoses and procedures
- Record every medication change with the reason
- Give each follow-up action an owner and a date
Frequently asked questions
Who reads the discharge summary?
The primary care physician first, and often the patient. Many teams also write a plain-language summary for the patient.
General guidance on clinical documentation, not advice about any individual patient and not legal advice.
Glossary
Look up related terms
- Medication reconciliationMedication reconciliation compares every list of a patient's medicines to produce one accurate list of what they actually take, with doses.
- HandoverA handover transfers responsibility for a patient from one clinician or team to another, with the information they need to continue care.