What should be included in a discharge summary (patient age, sex, admission date, primary admission diagnosis, comorbidities, hospital course, investigations, procedures, complications, discharge diagnoses, medication list with dose/route/frequency and changes, follow‑up appointments, recommended labs/imaging, criteria for urgent return, patient education, and discharging clinician’s name/contact)?

Essential Components of a Hospital Discharge Summary

A comprehensive discharge summary must include patient demographics, admission details, hospital course, medication reconciliation with specific dosing, follow-up plans, and clear return precautions—transmitted to the primary care provider within 24-48 hours of discharge to reduce readmission risk. 1

Critical Administrative Elements

Patient Identification and Timeline

• Patient age and sex must be documented at the top of the summary 2
• Admission date and discharge date establish the hospitalization timeline 2
• Primary admission diagnosis should be clearly stated as the principal reason for hospitalization 1, 3
• Complete list of comorbidities provides context for treatment decisions and ongoing care 1, 2

Provider Information

• Discharging clinician's name and contact information enables direct communication for clarification 1
• This contact information facilitates safe transitions when questions arise during outpatient follow-up 1

Clinical Content Requirements

Hospital Course Documentation

• Brief narrative of the hospitalization summarizing key clinical events from admission through discharge 2, 4
• All investigations performed including laboratory results, imaging studies, and diagnostic procedures with dates and key findings 1, 2
• Procedures completed during hospitalization with dates and any relevant complications 2, 5
• Complications encountered during the hospital stay, including adverse events and how they were managed 2, 5

Primary care clinicians rank hospital course as one of the four most important sections (95.5% concordance), so this should appear early in the document for maximal utility 4

Discharge Diagnoses

• Complete list of discharge diagnoses including both the primary diagnosis and all secondary conditions addressed during hospitalization 1, 2, 4
• This section was ranked as critically important by primary care providers in multi-institutional surveys 4

Medication Reconciliation (Critical Safety Element)

Complete Medication Documentation

• Every medication with exact dose, route, and frequency must be specified 1, 2
• Explicit documentation of medication changes comparing pre-admission to discharge regimens 1
• List of medications stopped during hospitalization to prevent inadvertent continuation 1
• New medications started with clear indication for each 1

Home and hospital medications must be cross-checked to ensure no chronic medications were inadvertently discontinued 1

Special Considerations for Diabetes Patients

• For patients with diabetes and HbA1c <7.5-8%, discharge on pre-hospitalization regimen 1
• For HbA1c 8-10%, consider oral agents plus 50% of hospital basal insulin dose 1
• For HbA1c >10%, discharge on basal-bolus regimen or combination therapy 1

Follow-Up and Transition Planning

Scheduled Appointments

• Specific follow-up appointments scheduled prior to discharge with date, time, and location 1
• Appointment with primary care provider within 1 month for all patients with hyperglycemia or significant medical issues 1
• Earlier appointment (1-2 weeks) if glycemic medications changed or glucose control suboptimal at discharge 1
• Scheduling appointments before discharge increases attendance rates compared to instructing patients to call for appointments 1

Recommended Testing

• Specific laboratory tests or imaging needed for outpatient follow-up with timeframes 2, 5
• Pending test results that require follow-up after discharge 1, 5

Patient Safety and Education

Return Precautions

• Specific criteria for urgent return to emergency department tailored to the patient's condition 2, 5
• Warning signs of complications specific to their diagnosis and procedures 1

Patient Education Documentation

• Identification of outpatient diabetes care provider (for diabetic patients) 1
• Level of understanding regarding diagnosis, self-monitoring, and home management goals 1
• Recognition and treatment of hyperglycemia and hypoglycemia (for diabetic patients) 1
• Medication administration instructions including insulin technique and disposal of supplies 1
• Sick-day management protocols 1
• Dietary counseling with referral to registered dietitian if needed 1

Transmission and Communication Standards

Timing Requirements

• Discharge summaries must be transmitted to the primary care provider as soon as possible after discharge, ideally within 24-48 hours 1
• Delayed summary availability increases readmission risk—summaries were available for only 12.2% of post-discharge visits in one study, and availability trended toward 26% reduction in readmission risk 6

Communication Format

• Information on medication changes, pending tests, and follow-up needs must be accurately communicated 1
• High-yield content should appear at the beginning of the summary for busy primary care clinicians 4
• Brief, succinct presentation is preferred over lengthy narratives 4

Common Pitfalls to Avoid

Documentation Errors

• Failing to reconcile pre-admission medications leads to inadvertent discontinuation of chronic therapies 1
• Omitting specific medication doses and frequencies creates confusion and medication errors 1
• Not documenting pending test results leads to lost follow-up of critical findings 1, 5

Communication Failures

• Delayed transmission of discharge summaries compromises continuity of care and increases readmission risk 6
• Lack of direct communication between inpatient and outpatient providers for complex cases 4
• Inadequate return precautions leave patients uncertain about when to seek urgent care 2, 5

Transition Planning Gaps

• Not scheduling follow-up appointments before discharge dramatically reduces attendance rates 1
• Failing to provide adequate medication supply until first post-discharge appointment 1
• Inadequate patient education about new diagnoses or medication changes 1

Special Population Considerations

Advance Care Planning

• Goals of care and advance directives should be documented in discharge summary if discussed or updated during hospitalization 1
• Substitute decision-maker information should be included per provincial/state legislation 1

Transitions to Long-Term Care

• Discharge summary must accompany patient to long-term care or rehabilitation facilities 1
• Functional, cognitive, and physical status assessments should be included for care planning 1