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Discharge Summaries

Comprehensive discharge summary structure meeting NHS documentation standards.

Purpose

Discharge summaries communicate essential clinical information to the GP and receiving clinicians at the point of discharge. They must be accurate, timely and complete.

Key Components

  • Admission and discharge dates
  • Admitting and discharging consultant
  • Principal diagnosis and secondary diagnoses
  • Summary of hospital admission
  • Procedures and operations performed
  • Investigations and results
  • Medications on discharge
  • Medications stopped and reasons
  • Allergies confirmed
  • Pending investigations and actions for GP
  • Outpatient follow-up arrangements
  • Patient / carer information provided
  • Functional status at discharge

Documentation Tips

  • Complete discharge summary before or on day of discharge
  • Clearly list all medication changes with reasons
  • Highlight pending results that need follow-up
  • Confirm allergies are accurately documented
  • Note any advance care planning discussions
Reminder: Always date, time and sign all clinical entries. Include your name and GMC/NMC number.
Template
DISCHARGE SUMMARY
=====================================
PATIENT: ______________________________
DOB: _____________  NHS No: ____________
ADDRESS: _____________________________

ADMISSION DATE: _______  DISCHARGE DATE: _______
ADMITTED VIA: _________________________
CONSULTANT: ___________________________
WARD: _________________________________

PRINCIPAL DIAGNOSIS:
_______________________________________

SECONDARY DIAGNOSES:
1.
2.

SUMMARY OF ADMISSION:
[Brief narrative of the admission]

PROCEDURES PERFORMED:
1.
2.

KEY INVESTIGATIONS:
[Relevant results summary]

PENDING INVESTIGATIONS / GP ACTIONS REQUIRED:
1.
2.

MEDICATIONS ON DISCHARGE:
Drug | Dose | Route | Frequency
_____|______|_______|_____________
     |      |       |
     |      |       |

MEDICATIONS STOPPED:
Drug | Reason
_____|________

ALLERGIES: ____________________________

FOLLOW-UP:
Outpatients: __________________________
With: _________________________________
Date: _________________________________
GP review: ____________________________

FUNCTIONAL STATUS AT DISCHARGE:
Mobility: _____________________________
Carer needs: __________________________

PATIENT INFORMATION PROVIDED: Yes / No

DISCHARGE TO: _________________________

SIGNATURE: ____________  DATE: _________
NAME (print): __________________________
COPY TO GP: ___________________________