What information should be included when writing a discharge summary?

How to Write Discharge Summaries

Discharge summaries should be structured, comprehensive documents that prioritize medication reconciliation, discharge diagnoses, hospital course, and follow-up plans, transmitted to the primary care provider as soon as possible after discharge—ideally on the day of discharge. 1

Core Components Required in Every Discharge Summary

Essential Clinical Information

• Discharge diagnoses: Document all primary and secondary diagnoses clearly without unexplained acronyms or jargon 2
• Hospital course summary: Include reason for admission, key clinical events, complications, and response to treatment 3, 2
• Medication reconciliation: Cross-check all medications to ensure no chronic medications were stopped inadvertently and verify safety of new prescriptions 1
  • List all discharge medications with dosages
  • Explicitly document medication changes from pre-admission regimen 2
  • Provide reasons for medication changes (only 32.1% of "successful" letters included this critical element) 2
  • Review new or changed prescriptions with patient and family at or before discharge 1

Diagnostic and Treatment Details

• Tests and procedures performed: Document all investigations completed during hospitalization 2
• Test and examination results: Include relevant laboratory values, imaging findings, and pathology results 2
• Hospital plan/actions taken: Specify interventions, procedures, and therapeutic decisions made during admission 2

Transition of Care Elements

• Follow-up plan for primary care provider: Clearly outline what the GP needs to do next, including monitoring requirements and pending tests 1, 2
• Outpatient appointments: Schedule follow-up appointments prior to discharge when possible, as this enhances appointment-keeping behavior 1
• Information provided to patient: Document what education and instructions were given to the patient 2
• Pending tests and studies: List any outstanding investigations that require follow-up 1

Disease-Specific Requirements

For Patients with Diabetes

• Identify the healthcare provider who will provide diabetes care after discharge 1
• Document patient's level of understanding regarding diabetes diagnosis, self-monitoring of blood glucose, home glucose goals, and when to call the provider 1
• Include education on hyperglycemia and hypoglycemia: Definition, recognition, treatment, and prevention 1
• Provide nutritional information: Document healthy food choices and referral to outpatient registered dietitian nutritionist if needed 1
• Specify insulin administration details: When and how to take blood glucose-lowering medications, including insulin administration technique 1
• Include sick-day management instructions 1
• Document proper use and disposal of needles and syringes 1
• Schedule early follow-up: Within 1-2 weeks if glycemic medications were changed or glucose control is not optimal at discharge 1

For Patients on Anticoagulation (e.g., Warfarin)

• Monitor PT/INR closely: Additional PT/INR determinations are essential in the period immediately after discharge from the hospital 4
• Document all medication interactions: Whenever other medications, including botanicals, are initiated, discontinued, or taken irregularly 4
• Specify target INR range and monitoring schedule 4

For Cardiac Rehabilitation Patients

• Document patient treatment plan: Evidence of patient assessment and priority short-term goals (weeks-months) within core components of care 1
• Include outcome report: Document patient outcomes reflecting progress toward goals, including appropriate medication doses (aspirin, clopidogrel, β-blockers, ACE inhibitors) and influenza vaccination status 1
• Provide discharge plan: Summarize long-term goals and strategies for success 1

Quality and Timeliness Standards

Timing Requirements

• Dictate on day of discharge: Summaries dictated on discharge day are more likely to be sent to outside physicians and include key content 5
• Transmit immediately to primary care provider: Discharge summaries should be transmitted as soon as possible after discharge 1
• Avoid delays beyond one week: Only 46.3% of summaries are dictated on discharge day, while 24.7% are completed more than a week after discharge—this is unacceptable 5

Communication Standards

• Ensure transmission to appropriate outpatient clinicians: 38.3% of discharge summaries are not sent to any outpatient physician—this represents a critical safety gap 5
• Use clear, jargon-free language: Unexplained acronyms and jargon appear in ≥70% of letters and compromise comprehension 2
• Present high-yield content first: Hospital course, discharge diagnoses, medication reconciliation, and follow-up sections should appear at the beginning 3
• Be concise and relevant: Primary care clinicians have limited time to review lengthy summaries 3

Common Pitfalls to Avoid

Content Deficiencies

• Missing medication change rationale: Only 32.1% of "successful" letters explain reasons for medication changes, yet this is critical for safe ongoing care 2
• Incomplete follow-up instructions: 30-47% of letters fail to specify what the GP needs to do next 2
• Omitting patient education documentation: Only 38.5% of "successful" letters document information provided to patient 2
• Failing to document pending tests: This creates dangerous gaps in continuity of care 1

Process Failures

• Retrospective completion from notes: Writing summaries days or weeks after discharge from memory or notes increases errors 2
• Junior physicians writing without supervision: Inexperienced clinicians often produce unclear, inaccurate summaries lacking important details 6
• Template restrictions: Rigid templates may prevent inclusion of essential individualized information 2
• No medication reconciliation: Failing to cross-check medications risks stopping chronic medications or creating unsafe drug interactions 1

Structured Approach: The "DISCHARGED" Framework

Diagnoses (primary and secondary)
Investigations (tests, procedures, results)
Summary of hospital course
Changes in medications (with rationale)
Handover plan for primary care
Appointments scheduled
Review with patient completed
Goals for ongoing care
Education provided
Discharge date and contact information 6

Implementation Strategies

For Individual Clinicians

• Complete summary on day of discharge before leaving the hospital 5
• Use standardized documentation templates that capture essential information from all team members 7
• Verify transmission to the correct outpatient provider before considering the discharge complete 5
• Avoid medical jargon and explain all acronyms 2

For Healthcare Systems

• Designate a discharge coordinator to facilitate communication between providers 7
• Implement structured discharge communication tools that ensure timely and effective information transfer 7
• Begin discharge planning at admission with input from all relevant disciplines 7
• Conduct regular audits to ensure quality of letters and reduce patient risk at discharge 2
• Provide interprofessional education on effective communication techniques 7