Ethan Rhodes
A discharge summary is a clinical report prepared by a health professional after a hospital stay or series of treatments. It is a formal document that serves as a primary mode of communication between the hospital care team and aftercare providers, such as the patient's GP. It is important to write a high-quality discharge summary as it can potentially impact the patient's care if errors are made. This document includes details such as the patient's discharge destination, presenting symptoms, salient investigations, referrals, and medication changes. It also provides a summary of the patient's hospital course, including consultations with specialists and their contributions. Writing an effective discharge summary involves structured training and adhering to specific guidelines to ensure clarity and accuracy in medical orders and patient instructions.
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What You'll Learn
Include presenting symptoms and signs
A discharge summary is a clinical report prepared by a health professional after a hospital stay or series of treatments. It is often the primary mode of communication between the hospital care team and aftercare providers, such as the patient's GP. It is a legal document, and errors can potentially jeopardize the patient's care.
When including presenting symptoms and signs, it is important to provide a focused summary. For example, "Mrs Smith presented to A&E with worsening shortness of breath and ankle swelling. On arrival, she was tachypnoeic and hypoxic (oxygen saturation of 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."
It is also important to include salient investigations performed during the patient's admission. For example, "Blood tests revealed a raised BNP. An ECG showed evidence of left-ventricular hypertrophy, and echocardiography revealed grossly impaired ventricular function (ejection fraction 35%)".
In addition, be sure to include any referrals made by the hospital, such as a referral to a chronic pain team. For example, "We have discharged Mrs Smith on regular oral Furosemide (40mg OD) and we have requested an outpatient ultrasound of her renal tract, to be performed in the next few weeks. We will review Mrs Smith in the Cardiology Outpatient Clinic in 6 weeks. 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. For instance, "Could you please arrange for Mrs Smith’s U&Es to be assessed in 2 weeks, to ensure her creatinine and electrolytes remain stable on her new diuretic regime. Should you have any questions or concerns, please do not hesitate to contact our team on [insert telephone number]."
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Summarise salient investigations
A discharge summary is a clinical report prepared by a health professional after a hospital stay or series of treatments. It is a legal document that serves as the primary mode of communication between the hospital care team and aftercare providers, such as the patient's GP. It is important to summarise salient investigations and include them in the discharge summary.
Salient Investigations
Upon admission, the patient underwent the following radiology tests in the emergency room: [list the tests and their findings].
Blood Tests
- Raised BNP levels were detected.
- [Include any other relevant blood test results and their implications].
Cardiac Assessments
- An ECG revealed left-ventricular hypertrophy.
- Echocardiography showed grossly impaired ventricular function with an ejection fraction of 35%.
- [Add any further cardiac investigations and their outcomes].
Additional Investigations
[List any other significant tests or examinations and their results, such as imaging scans, biopsy results, or specialist evaluations].
It is crucial to provide a concise summary of the salient investigations, including any abnormal findings and their clinical significance. This information aids the receiving healthcare providers in quickly identifying specific issues and facilitates efficient patient care and follow-up.
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Outline treatment and medication changes
A discharge summary is a clinical report prepared by a health professional after a hospital stay or series of treatments. It is a legal document that outlines the patient's hospital stay, including investigation results, diagnoses, management, and follow-up plans. It is important to write clear and concise summaries to ensure effective communication between the hospital care team and aftercare providers, such as the patient's GP.
When outlining treatment and medication changes in a discharge summary, it is crucial to provide a detailed and accurate account. Here is a suggested outline for this section:
Treatment and Medication Changes:
Paragraph 1: Start by providing an overview of the patient's treatment journey during their hospital stay. This includes the specialists consulted and their respective contributions. For example, "During the patient's hospitalisation, a multidisciplinary team comprising specialists from cardiology, nephrology, and respiratory medicine was involved in their care. The cardiology team performed a thorough evaluation, including an ECG and echocardiography, which revealed left ventricular hypertrophy and impaired ventricular function."
Paragraph 2: Discuss the specific treatments administered for each admitting diagnosis. For instance, "The patient was initially started on Levaquin and Flagyl IV antibiotics upon admission to address the suspected infectious etiology of their symptoms." Provide details of any procedures or interventions performed, such as surgeries, therapies, or diagnostic tests, and their outcomes.
Paragraph 3: Outline any changes made to the patient's medication regimen during their hospital stay. Clearly state the medications that were started, stopped, or modified, along with the rationale behind these decisions. For example, "Mrs Smith's medication regimen was adjusted during her hospital course. Furosemide (40mg orally daily) was initiated to manage fluid retention and improve cardiac function. Additionally, we tapered and discontinued her previous diuretic, as it was less effective in controlling her symptoms."
Paragraph 4: Provide a comprehensive list of the patient's discharge medications, including doses, routes, and frequency, and any relevant instructions. For example, "Upon discharge, Mrs Smith was prescribed the following medications: Furosemide 40mg orally once daily, to be taken in the morning; Bisoprolol 5mg orally once daily for blood pressure control; and Aspirin 75mg orally once daily for cardiovascular protection. It is essential to take these medications as directed and not to discontinue or modify them without medical advice."
Paragraph 5: Discuss any referrals or follow-up appointments made by the hospital team. This includes consultations with specialists, outpatient procedures, or therapy sessions. For instance, "We have arranged for Mrs Smith to be reviewed in the Cardiology Outpatient Clinic in six weeks to monitor her cardiac function and response to the new medication regimen. Additionally, we have requested an outpatient ultrasound of her renal tract to further evaluate her kidney function."
Paragraph 6: Conclude by summarising any specific instructions or actions required from the patient's GP or aftercare providers. For example, "Mrs Smith's GP is requested to arrange for a renal function test, including U&Es, within two weeks to ensure her creatinine and electrolytes remain stable on the new diuretic regime. Our team is available for any further consultations or queries regarding her care plan."
Remember to adapt each summary to the specific clinical context and include only relevant information. Clear and concise communication is essential to ensure a smooth transition from hospital care to ongoing outpatient management.
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List discharge medications
When writing a discharge summary, it is important to list all medications the patient needs to take after leaving the hospital, including doses, routes, and frequency. If there are medications that the patient took prior to hospital admission that should no longer be continued, briefly explain why they have been stopped. Any changes to the patient's medication during their hospital stay should also be noted, along with the rationale behind them.
- Medication 1: [name of medication], [dose], [route], [frequency].
- Medication 2: [name of medication], [dose], [route], [frequency].
- If applicable, explain any medications that have been stopped or changed during the patient's hospital stay.
It is crucial to provide clear and concise information about the patient's medications to ensure continuity of care and avoid potential adverse events. This section of the discharge summary plays a vital role in keeping the patient safe and helping them understand their ongoing treatment plan.
Additionally, it is important to include any relevant information about follow-up appointments or further actions related to the patient's medication plan. For example, if the patient needs to schedule a follow-up appointment with a specialist to monitor their medication response, this should be noted here.
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Provide discharge destination
A discharge summary is a clinical report prepared by a health professional after a hospital stay or series of treatments. It is a formal document that serves as a primary mode of communication between the hospital care team and aftercare providers, such as the patient's GP. It is important to write clear and concise summaries to avoid errors that may jeopardize the patient's care.
When providing discharge destination information, it is essential to include the patient's destination after leaving the hospital, such as returning home or going to a residential care home. This section should also include a summary of the patient's presenting symptoms and signs, as well as any salient investigations performed during their hospital admission. For example:
"The patient is being discharged to [destination, e.g., home address or name of the care facility]. They presented to the emergency department with [presenting symptoms and signs, e.g., worsening shortness of breath and ankle swelling]. Clinical examinations revealed [significant findings, e.g., reduced breath sounds and bilateral lung base dullness]. Investigations during admission included [relevant tests and results, e.g., blood tests showing raised BNP and echocardiography revealing impaired ventricular function]."
It is important to provide a clear and concise summary of the patient's condition and the results of any relevant investigations to ensure a smooth transition to the next stage of their care. This information assists the receiving healthcare providers and helps them quickly identify and address specific issues or problems.
Additionally, it is crucial to document any referrals made by the hospital, such as referrals to specialist teams or requests for outpatient procedures. For example:
"We have arranged for the patient to be discharged to [destination, e.g., home address]. We have referred them to the [specialist team, e.g., chronic pain team] for ongoing management. We have also requested an outpatient [procedure, e.g., ultrasound of the renal tract], which will be performed in the next [timeframe, e.g., few weeks]. A follow-up appointment has been scheduled at our [clinic name, e.g., Cardiology Outpatient Clinic] in [timeframe, e.g., six weeks]."
By providing detailed information about the patient's discharge destination and any relevant referrals or procedures, the discharge summary ensures effective communication between healthcare providers and facilitates seamless continuity of care for the patient.
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Frequently asked questions
A discharge summary is a clinical report prepared by a health professional after a hospital stay or series of treatments. It is often the primary mode of communication between the hospital care team and aftercare providers.
A discharge summary should include the patient's discharge destination, a summary of their presenting symptoms and signs, salient investigations performed during their admission, referrals made by the hospital, and any actions to be taken by the patient's GP after discharge. It should also include a summary of the patient's hospital stay, including investigation results, diagnoses, management, and follow-up.
A discharge summary should be written in plain English, with short sentences and one topic per paragraph. Technical terms should be explained, and any instructions for the patient should repeat what was explained before discharge.
The discharge summary should list all medications the patient needs to take at home, including doses, route, frequency, and the date of the last dose. If there have been any changes to the patient's medications, these should be noted, along with the rationale.
