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Discharging patients from a hospital is a complex task. An essential part of this process is the documentation of a discharge summary. A discharge summary is a clinical report prepared by a health professional at the conclusion of a hospital stay or series of treatments. It is often the primary mode of communication between the hospital care team and aftercare providers. It is considered a legal document and it has the potential to jeopardize the patient’s care if errors are made. Delays in the completion of the discharge summary are associated with higher rates of readmission, highlighting the importance of successful transmission of this document in a timely fashion.

This guide will help you to understand what’s necessary to include and give you a structure to effectively write discharge summaries. It gives a detailed description of each section that may be included in a typical discharge summary. Each section illustrates key pieces of information that should be included and aims to explain the rationale behind each part of the document.

In practice, each summary is adapted to the clinical context. As such, not all information included in this guide is relevant and needs to be mentioned in each discharge summary. In addition, different hospitals have different criteria to be included and you should always follow your hospital’s or medical school’s guidelines for documentation.

 


Demographics

Patient details

Important information to include regarding the patient includes:

  • Patient Name – full name of the patient (also the patient’s preferred name if relevant)
  • Date of Birth
  • Unique Identification Number
  • Patient Address – the usual place of residence of the patient
  • Patient Telephone Number
  • Patient Sex – sex at birth (this determines how the individual will be treated clinically)
  • Gender – the gender the patient identifies with
  • Ethnicity – ethnicity as specified by the patient
  • Next of kin/Emergency Contact – full name, relationship to the patient and contact details

 

GP details

This section should be completed with the details of the General Practitioner with whom the patient is registered:

  • GP Name – the patient’s usual GP
  • GP Practice Details – name, address, email, telephone number and fax of the patient’s registered GP practice
  • GP Practice Identifier – a national code which identifies the practice

 

 

Hospital details 

This section should encompass the salient aspects of the patient’s discharge:

  • Discharging Consultant – the consultant responsible for the patient at the time of discharge
  • Discharging Specialty/Department – the specialty/department responsible for the patient at the time of discharge
  • Date and Time of Admission and Discharge
  • Discharge Destination – destination of the patient on discharge from hospital (e.g. home, residential care home)

 


Clinical Details

Presentation

History and Examination Findings

Include a focused summary of the patient’s presenting symptoms and signs:

  • “Mrs Smith presented to A&E with worsening shortness of breath and ankle swelling. On arrival, she was tachypnoeic and hypoxic (oxygen saturation 82% on air). Clinical examination revealed reduced breath sounds and dullness to percussion in both lung bases. There was also a significant degree of lower limb oedema extending up to the mid-thigh bilaterally.”

 

 

Investigations

Include salient investigations performed during the patient’s admission:

  • “Blood tests revealed a raised BNP. An ECG showed evidence of left-ventricular hypertrophy and echocardiography showed grossly impaired ventricular function (ejection fraction 35%). A chest x-ray demonstrated bilateral pleural effusions, with evidence of upper lobe diversion.”

 

Include any investigations that are still pending:

  • “A renal tract ultrasound has been requested and will be performed in the next 2 weeks. We will write to you with the results.”

 

Diagnoses

This section should include the diagnosis or diagnoses that were made during the patient’s stay in hospital:

  • “Mrs Smith was reviewed by the Cardiology team who confirmed a diagnosis of congestive heart failure.”

 

If no diagnosis was confirmed, use the presenting complaint and explain no cause was identified:

  • “No clear cause was identified for the patient’s chest pain at this time.”

 

Be as specific as possible when documenting diagnoses. Some examples of diagnoses for which you should include specific details include:

  • Diabetes – type 1, type 2, steroid induced, gestational
  • Myocardial Infarction – NSTEMI, STEMI
  • Pneumonia – bacterial, viral, aspiration pneumonia
  • Septicaemia – causative organism and source (e.g. E.Coli urosepsis)
  • Gastroenteritis – viral, bacterial

 

Management

Explain how the patient was managed during their hospital stay and include any long term management that has been initiated:

  • “Mrs Smith required oxygen and intravenous diuretic therapy for the first 24 hours of her admission. She was then weaned off oxygen and commenced on regular oral furosemide (40mg OD) which is to be continued after discharge. At discharge, Mrs Smith’s symptoms were much improved and she was able to mobilise independently with only mild shortness of breath on exertion.”

Complications

Document any complications that occurred during the patient’s hospital stay:

  • “Mrs Smith developed a stage 2 acute kidney injury after initiation of diuretic therapy, however, this resolved with dose titration and careful fluid balance management. Her baseline creatinine at discharge was 74 μmol/ L.”

 

Procedures

This section must include all operations or procedures that the patient underwent:

  • Date of Procedure(s) – the date the procedure(s) was/were performed
  • Procedure – the procedure performed (e.g. laparoscopic appendectomy)
  • Complications Related to the Procedure – details of any intra-operative complications encountered during the procedure, arising during the patient’s stay in the recovery unit or directly attributable to the procedure (e.g. injury to surrounding structures, secondary wound infections, etc)
  • Specific Anaesthesia Issues – details of any adverse reaction to any anaesthetic agents including local anaesthesia (e.g. difficult intubation, allergic reaction to a particular anaesthetic agent)


Future Management

Include details of the current plan to manage the patient and their condition(s) after discharge from hospital:

  • Treatments (e.g. medication, surgery, etc)
  • Hospital follow up
  • Referrals made by the hospital (e.g. referral to chronic pain team)
  • “We have discharged Mrs Smith on regular oral Furosemide (40mg OD) and we have requested an outpatient ultrasound of her renal tract which will be performed in the next few weeks. We will review Mrs Smith in the Cardiology Outpatient Clinic in 6 weeks time. After review from our social worker and occupational therapist, we have arranged a once daily care package to assist Mrs Smith with her activities of daily living.”

 

Clearly document any actions you would like the patient’s GP to perform after discharge:

  • “Could you please arrange for Mrs Smith’s U&Es to be assessed in 2 weeks time, to ensure her creatinine and electrolytes remain stable on her new diuretic regime. Should you have any questions or concerns in the meantime, please don’t hesitate to contact our team.”

 


Medications

Medication changes

Summarise any changes to the patient’s regular medication and provide an explanation as to why the changes were made if possible:

  • “Amlodipine INCREASED to 10mg once daily to improve blood pressure control.”
  • “Citalopram 20mg once daily COMMENCED due to low mood.”
  • “Furosemide 40mg once daily STOPPED due to acute kidney injury.”

 

Medications to take home

You should include a list of all medications that the patient is currently taking, including:

  • Regular medications
  • As required (PRN) medications

 

For each medication, you should include details regarding the following:

  • Name – usually, generic drug names are preferred, but in some cases using the specific brand name is more appropriate (e.g. epilepsy medication)
  • Form – capsule, drops, tablet, lotion, etc
  • Route – oral, inhaled, topic, intravenous, etc
  • Frequency – once daily, twice daily, as required, etc
  • Duration – x days, long-term, etc
  • Indication – e.g. congestive heart failure
  • Additional Instructions – review date, monitoring requirements, etc

 


Allergies and Adverse Reactions

This section should outline any allergies or adverse reactions that the patient experienced. It should be as specific as possible and include the following:

  • Causative Agent – the agent (food, drug or substances) that caused an allergic reaction or adverse reaction
  • Description of the Reaction – this may include the manifestation (e.g. rash), type of reaction (allergic, adverse, intolerance), the severity of the reaction
  • Date First Experienced – when the reaction was first experienced

 


Information for the patient

Most discharge letters include a section that summarises the key information of the patient’s hospital stay in patient-friendly language, including investigation results, diagnoses, management and follow up. This is often given to the patient at discharge or posted out to the patient’s home:

  • “You were admitted to hospital because of worsening shortness of breath and swelling of your ankles. We performed a number of tests which revealed that your heart wasn’t pumping as effectively as it should have been. As a result, we have started you on a water tablet called Furosemide, which should help to keep fluid from building up in your legs and lungs. You should continue to take the Furosemide tablet as prescribed, however, if you become unwell, you should see your GP as this tablet can potentially damage your kidneys if you become dehydrated. We plan to review you in 6 weeks time, in the Cardiology Outpatient Clinic and we will send your appointment details out in the post. We have also asked your GP to take some blood tests to check your kidney function in around 2 weeks time. In the meantime, should you have any concerns or questions, you should see your GP.” 

 


Person Completing Record

This section includes personal information about the healthcare provider completing the discharge summary:

  • Name
  • Designation or role
  • Grade
  • Specialty
  • Date completed


Other sections that may be included

Assessment Scales

This section identifies any assessment scales used when clinically evaluating the patient. Some examples of assessment scales commonly used include:

  • New York Heart Association (NYHA) Functional Classification
  • Cognitive function (e.g. MMSE)
  • Mood assessment scales
  • Malnutrition Universal Screening Tool (MUST)

 

Social Context

Household Composition:

  • Who the patient lives with (e.g. lives alone, lives with a partner, lives with family)
  • Details of the patient’s residence (e.g. house with stairs, bungalow, flat, residential care, etc)

 

Occupational History:

  • Current and/or previous relevant occupation(s) of the patient

 

Special Requirements

Does the patient have any special requirements?

  • Transport arrangements (e.g. ambulance with oxygen)
  • Language (e.g. preferred language, need for an interpreter)
  • Advocate requirements

 

Participation in Research

This is to clearly identify patients who are involved in a clinical trial.

This may include:

  • Whether participation in a trial has been offered, refused or accepted
  • Name of the trial
  • Drug/Intervention tested
  • Enrolment date
  • Duration of treatment and follow up
  • A contact number for adverse events or queries

Legal Information

This section describes the care of the patient from a legal perspective. Some examples of the types of information it may include are shown below.

 

Consent for Treatment Record:

  • Whether consent has been obtained for the treatment

 

Mental Capacity Assessment:

  • Whether an assessment of the mental capacity of the (adult) patient has been undertaken, if so, who carried it out, when it was carried out and the outcome of the assessment

 

Advance Decisions about Treatment:

  • Whether there are written documents, completed and signed when a person is legally competent, that explains a person’s medical wishes in advance, allowing someone else to make treatment decisions on his/her behalf late in the disease process
  • Location of these documents
  • A copy of the document itself

 

Lasting or Enduring Power of Attorney or Similar:

  • Record of individual involved in healthcare decision on behalf of the patient if the patient lacks capacity

 

Organ and Tissue Donation:

  • Has the person given consent for organ and/or tissue donation?

 

Consent Relating to Child: 

  • Consideration of age and competency
  • Record of the person with parental responsibility, or appointed guardian where a child lacks competency

 

Consent to Information Sharing:

  • Record of consent to information sharing, including any restrictions on sharing information with others (e.g. family members, other healthcare professionals)
  • Use of identifiable information for research purposes

 

Safeguarding Issues:

  • Any legal matters relating to the safeguarding of a vulnerable child or adult (e.g. child protection plan, a child in need plan, protection of a vulnerable adult)

 

Safety Alerts

This section illustrates if the patient poses a risk to themselves, for example, suicide, overdose, self-harm, self-neglect. Also include if the patient is a risk to others, including professionals or any third party.

 

Patient and Carer Concerns

This section should include a description of any concerns of the patient and/or carer.

 


References

1. Health and Social Care Information Centre, Academy of Medical Royal Colleges. Standards for the clinical structure and content of patient records [Internet]. London: Health and Social Care Information Centre, Academy of Medical Royal Colleges; 2013 p. 37 – 44. Available from: [LINK]

2. UpToDate [Internet]. Uptodate.com. 2019 [cited 28 January 2019]. Available from: [LINK]

 


 

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