Discharge Summary Template
This discharge summary template is designed to assist hospital personnel in thoroughly recording the patient's medical journey and exit guidelines. With this template, you can:
- Establish a coherent and organized account of the patient’s treatment, key incidents, and alterations in condition during their stay
- Capture the most essential discharge details for treatment methods, clinical progress, and guidance for follow-up care
- Auto-populate critical and relevant patient data, including diagnoses, lab results, procedures, and medication lists
What is a Discharge Summary Template?
A discharge summary template helps doctors effectively document a patient’s hospital stay, including diagnosis, treatments, significant events, and follow-up instructions for their GPs.
It serves as a clinical handover tool for healthcare providers to ensure continuity of care and proper management of the patient's health after leaving the hospital.
In the following sections, we’ll explore the difference between a discharge summary and after visit summary, essential details that should be included in a discharge summary, advantages of using a discharge summary template, how to write a discharge summary with examples, and featured templates.
Discharge Summary vs After Visit Summary
A discharge summary and an after visit summary (AVS) both document patient care in hospital settings, but they serve different purposes.
A discharge summary is a report provided to healthcare providers when a patient leaves the hospital. It outlines the patient’s hospital stay, treatments received, and guidelines for follow-up care to ensure ongoing care.
On the other hand, an after visit summary is a simpler document given to patients after a doctor's appointment. It includes the diagnosis, prescribed medications, and self-care tips to help them continue their treatment effectively.
Importantly, an after visit summary also uses plain-language and avoids medical jargon to be more accessible for patients to better understand the care they have received and important next steps.
Most Crucial Details of Discharge Summary Templates
Many healthcare providers, from doctors to nurses, report challenges in effectively writing and receiving discharge summaries, often chasing missing details and working overtime to complete them. Incomplete or unclear summaries can lead to harmful medication errors, delayed follow-ups, and fragmented patient care.
A well-structured discharge summary should be concise, clinically relevant, and actionable, ensuring a seamless transition from hospital to outpatient care. With that, here are the 10 crucial elements that you should include when writing discharge summaries:
1. Patient Information
This details the patient’s full name, date of birth, medical record number (MRN) or equivalent, and contact details to ensure accurate identification and prevent administrative errors. Include sex, gender, and address where required for compliance.
2. Healthcare Details, including Admission and Discharge Dates
This contains the hospital name, unit or ward, local health district (if applicable), and attending physician. Also include admission and discharge dates to provide clear context on the length of hospital stay and treatment timeframe.
3. Primary Diagnosis with Secondary Diagnoses and Comorbidities
This includes the main reason for admission, ensuring GPs and community teams understand the core issue (or issues) requiring follow-up. Any pre-existing or newly diagnosed conditions that might impact ongoing care and medication management should be present as well.
4. Summary of Hospital Stay
This is a brief timeline of key interventions, procedures and treatments provided, significant investigations, and notable clinical events, avoiding unnecessary details. If the patient spent time in ICU or required high-dependency care, provide a brief summary of their stay and progression.
5. Medication List
Clearly categorize medications on discharge into:
- New medications (started during admission)
- Changed medications (adjusted dosage or formulation)
- Unchanged medications (continued from prior regimen)
- Ceased medications (ceased during admission)
Include dose, route, frequency, duration, and indication for each drug. Ceased or temporarily suspended medications must be listed with reasons for discontinuation. Further, list all surgeries, interventional procedures, and key medical treatments performed during admission.
6. Allergies and Other Special Considerations
Document medication, food, or environmental allergies with a clear reaction type (e.g., anaphylaxis, rash). If the patient has no known allergies, state “Nil known” explicitly to prevent uncertainty.
Any infection risks, fall risks, anticoagulation therapy, or cognitive impairments requiring special handling should also be clearly indicated.
7. Follow-up Plans and Pending Results
Specify who is responsible for each follow-up action (e.g., GP, specialist, allied health) and flag pending investigations with instructions on the next steps. Additionally, scheduled follow-up appointments should include date, time, location, and provider details.
8. Patient Advice and Self-Care Instructions
Provide plain-language guidance on diet, mobility, wound care, medication adherence, and red-flag symptoms that need urgent medical attention. Where possible, use patient-friendly formats and avoid medical jargon for clarity.
While core elements of a discharge summary are generally similar, specific requirements may vary based on national or regional regulations. Below are some of the particular requirements for discharge summaries for the following countries:
- In the United States, the Centers for Medicare & Medicaid Services (CMS) require that discharge summaries must be completed immediately after discharge and there is special emphasis placed on ensuring accurate transfer of information to post-acute care providers to prevent treatment disruptions and reduce readmission.
- In Canada, hospitals must send discharge summaries to primary care providers within 48 hours, with a focus on medication reconciliation to prevent discrepancies. As per Accreditation Canada, medication lists must be cross-checked against the Best Possible Medication History (BPMH) and shared with community pharmacists to ensure safe transitions.
- In Australia, discharge summaries, following the recommended formats in the Australian Commission on Safety and Quality in Healthcare (ACSQHC) guidelines, must be integrated into My Health Record (MHR). Another unique requirement for Australia is that medications must be categorized as new, changed, or unchanged, with clear justifications for adjustments or discontinuations.
- In the United Kingdom, the states that hospitals must send digital discharge summaries to GPs within 24 hours. Other specific requirements include documenting social risk factors (e.g. housing stability, caregiver support), specialist referrals, and allergies to ensure post-discharge support is comprehensive.
Advantages of a Discharge Summary Template
Freewriting discharge summaries often lack key details or become overly lengthy. The best way to avoid these pitfalls is by using a structured template for discharge summaries, ensuring efficiency and consistency. With that, here are 6 ways a discharge summary template can improve your documentation:
Reduces After-Shift Documentation Fatigue
A well-structured template provides pre-filled sections and standardized fields, so doctors and nurses aren’t starting from scratch every time. This prevents decision fatigue, speeds up completion, and reduces the need to stay later than needed to complete summaries after an exhausting shift.
Improves Continuity of Care
Standardised fields ensure that all critical details—diagnosis, treatments, and follow-up plans—are consistently recorded. This minimises the risk of missing essential information when transitioning care to GPs and community teams. Missing information can reduce the quality of follow-up care a patient receives in the community.
Prevents Medication Errors and Follow-Up Gaps
Missing or unclear discharge summaries can lead to incorrect prescriptions, untracked pending test results, and preventable readmissions. A structured format ensures that medication adjustments, allergies, and pending labs are clearly documented, preventing serious errors and potential patient harm from occurring.
Simplifies Compliance with Legal and Medical Standards
A template helps meet national guidelines and hospital policies by ensuring summaries contain the necessary clinical and administrative information. This reduces the risk of medico-legal issues and ensures records are audit-ready.
Supports More Effective Multidisciplinary Collaboration
Documentation of discharge summaries and other critical medical records that require collaborative input from multiple healthcare teams can often become disorganized—leading to miscommunication, follow-up gaps, and increased administrative burden.
Dr. Shelagh Fraser, Director of Medical Excellence and Innovation at Priority Physicians, mentioned that after discovering Heidi, an AI-powered medical scribe, she became convinced that the tool could not only improve work-life balance for her team but also enhance the quality of care for their patients.
As she put it, “Previously, I would spend 2-2.5 hours writing notes for a full day of seeing patients. Now with Heidi, I’ve got that down to around 40 minutes.” And with single-patient team collaboration, her team members can now securely contribute to notes using their own Heidi accounts—eliminating the need for risky workarounds while ensuring seamless, efficient documentation.
Whether it's hospital physicians, nurses, therapists, or social workers, a concise discharge summary ensures all care team members understand a patient's journey, improving coordination and reducing follow-ups.
Tips to Write a Good Discharge Summary
Having a well-formatted template for discharge summaries containing the crucial details is a good start, but effective documentation goes beyond structure. To help ensure that we’re preparing discharge summary in the best interest of anyone who will consume it, here are some essential tips to keep in mind:
Keep it concise but informative.
A discharge summary should be clear, direct, and clinically useful with all salient details from an admission included. While it doesn’t need to be a novel, it should provide enough detail for outpatient providers and future hospital teams to understand the admission, necessary follow-ups, and provide a holistic view of a patient’s medical history.
Start early for complex cases.
If a patient has a prolonged or complicated hospital stay, begin drafting the summary as early as day 2 or 3. This avoids last-minute rushing and ensures that key details are accurately recorded while still fresh in your mind.
Summarize, don’t narrate.
Avoid a day-by-day play-by-play of every event during admission. Focus on major clinical decisions, key investigations, and any changes in management that impact ongoing care.
Consider your audience—beyond hospital staff.
Your summary isn’t just for other residents or consultants; it gets faxed to GPs, nurses, pharmacists, and other health professionals alike, many of whom don’t use the same shorthand. Avoid excessive abbreviations to prevent confusion and misinterpretation of instructions.
Be mindful of patient readability.
Patients and their families may access the discharge summary, so choose your wording carefully. Avoid overly technical or judgmental language (e.g., "non-compliant patient"), and instead use objective, professional descriptions that maintain trust and clarity.
Different Formats of a Discharge Summary Template
Discharge summary template formats differ by hospital and EMR systems, but they all aim to give a clear and concise overview of a patient's hospital stay and follow-up care needs. Here are the most common formats:
1. Narrative Format
This discharge template format is a free-text, paragraph-style summary that provides a chronological account of the patient’s hospital stay, including admission, key events, treatments, and discharge plans.
Example: Narrative Discharge Summary Template
The narrative format for discharge summaries is ideal for complex cases that require detailed context (e.g., multi-organ failure, prolonged ICU stays) but it can also become too lengthy and difficult to scan, making it harder for outpatient providers to find key details quickly.
2. Bullet Point Format
This discharge template format presents patient information in a structured, itemized list, making it easy to scan. It highlights key aspects of the hospital stay, including admission details, primary diagnosis, major interventions, and discharge instructions in a concise manner.
Example: Bullet Point Discharge Summary Template
Using bullet points in discharge summaries is especially useful for straightforward cases with clear diagnoses and treatments (e.g., routine surgeries, short hospital stays). However, it may lack the nuanced clinical context needed for complex cases, making it harder to understand the full narrative of the patient’s hospital course.
3. Problem-Based Format
This format organizes information under each active medical problem addressed during hospitalization.
Example: Problem Based Inpatient Discharge Summary Template
Following the problem-based approach is can be most helpful for patients with multiple comorbidities requiring detailed, condition-specific follow-up care. In some instances, it may not provide a fluid summary of the hospital course, making it harder to grasp the overall treatment timeline.
What is the Best Discharge Summary Template Format?
The best format hinges on the clinical setting, case complexity, and the needs of healthcare providers. Often, a hybrid format—melding structure with brief narrative notes—offers clarity and completeness.
Discharge Summary Template Sample PDF
Discharge Summary Examples
A well-written discharge summary provides clear, concise, and actionable information to GPs, nurses, and other healthcare providers. Below are three specific examples tailored to different use cases:
1. General Hospital Discharge Summary Example
Patient & Hospital Details
- Patient Name: John Doe
- Date of Birth: 12 June 1952 (73 years old)
- Medical Record Number (MRN): [123456]
- Date of Admission: 10 January 2025
- Date of Discharge: 15 January 2025
- Hospital Name & Ward: City General Hospital – Respiratory Unit
- Attending Physician: Dr. James Patterson
- Primary Care Provider (PCP): Dr. Sarah Mitchell, Riverside Family Clinic
Diagnosis & Clinical Course
- Admission Diagnosis: Community-acquired pneumonia requiring oxygen therapy
- Discharge Diagnosis: Resolved pneumonia, improved oxygenation on room air
- Secondary Diagnoses: Hypertension, Type 2 Diabetes, Chronic Kidney Disease (Stage 3)
Hospital Stay Summary
- Consultations:
- Infectious Disease (for antibiotic selection and duration guidance)
- Pulmonology (for persistent hypoxia and weaning oxygen)
- Procedures: None
- History of Present Illness (HPI):
- 72-year-old male presented with worsening dyspnea, productive cough, and fever.
- Chest X-ray showed right lower lobe consolidation, consistent with pneumonia.
- Empiric treatment started with IV ceftriaxone and azithromycin; required supplemental oxygen at 2L NC.
- Brief Hospital Course:
- Gradual improvement noted with IV antibiotics.
- Repeat CXR on Day 4 showed resolving infiltrates.
- Oxygen therapy weaned off by Day 5.
- Blood cultures remained negative throughout admission.
- Transitioned to oral levofloxacin 750mg daily on Day 6 for completion of treatment.
Pending & Follow-Up Needs
- Pending Lab or Test Results: None
- Immunizations Given During Admission: Influenza vaccine administered on 12 March 2024
- Alerts & Special Considerations:
- Chronic Kidney Disease (Stage 3) – Avoid nephrotoxic medications; monitor renal function.
- Diabetes Mellitus – Monitor for signs of worsening glycemic control due to infection recovery.
Discharge Plan
- Discharge Disposition: Home with caregiver support and self-monitoring
- Dietary Recommendations: Low-sodium, diabetic diet with adequate hydration
Discharge Medications
- Levofloxacin 750mg PO daily for 5 more days (to complete pneumonia treatment)
- Lisinopril 10mg PO daily (resumed home dose for hypertension)
- Metformin 500mg PO BID (unchanged; continue regular monitoring of blood glucose levels)
Discharge Instructions
- Monitor for:
- Fever, worsening dyspnea, or new-onset chest pain (seek immediate medical attention if present).
- Symptoms of dehydration, hypoglycemia, or signs of medication side effects.
- Medication adherence is critical—complete the antibiotic course as prescribed.
- Gradual activity resumption recommended; avoid excessive exertion for the next 2 weeks.
Follow-Up Appointments
- Primary Care Physician (PCP): Dr. Sarah Mitchell, Riverside Family Clinic – 20 March 2024 (for medication review and overall recovery assessment)
- Pulmonology Referral: Dr. Anne Roberts, City Hospital Pulmonary Clinic – 5 April 2024 (for follow-up imaging and respiratory function assessment)
Copies Sent To:
- Primary Care Provider (PCP): Dr. Sarah Mitchell, Riverside Family Clinic
2. Behavioral Health Discharge Summary Example
Patient & Hospital Details
- Patient & Hospital Details
- Patient Name: Jane Doe
- Date of Birth: 15 August 1988 (36 years old)
- Medical Record Number (MRN): [789654]
- Date of Admission: 5 December 2024
- Date of Discharge: 12 December 2024
- Hospital Name & Unit: City Behavioral Health Center – Inpatient Psychiatry
- Attending Psychiatrist: Dr. Lisa Carter
- Outpatient Provider: Dr. Emily Henshaw, Willow Behavioral Health
Diagnosis & Clinical Course
- Admission Diagnosis: Major Depressive Disorder, Severe with Suicidal Ideation
- Discharge Diagnosis: Major Depressive Disorder, in partial remission
- Secondary Diagnoses: Generalized Anxiety Disorder, History of Alcohol Use Disorder (in remission)
Hospital Stay Summary
- Consultations:
- Psychology – Cognitive Behavioral Therapy (CBT) initiated
- Social Work – Discharge planning and coordination of outpatient care
- Procedures: None
- History of Present Illness (HPI):
- 35-year-old female presented with worsening depression, suicidal ideation, and recent psychosocial stressors, including job loss.
- Voluntarily sought care at the Emergency Department following family intervention.
- Admitted for safety, stabilization, and medication management.
- Brief Hospital Course:
- Initiated on sertraline 50mg PO daily for depression.
- Hydroxyzine 25mg PO PRN (up to 3x daily) prescribed for anxiety.
- Participated in group therapy, individual psychotherapy, and Dialectical Behavior Therapy (DBT) skills training.
- No further suicidal ideation by Day 5; mood improved but remains at risk of relapse.
- Social worker arranged outpatient therapy and follow-up psychiatric care.
Pending & Follow-Up Needs
- Pending Lab or Test Results: None
- Immunizations Given During Admission: None
- Alerts & Special Considerations:
- History of suicidal ideation – High-risk period post-discharge; monitor closely for relapse signs.
- Alcohol Use Disorder (in remission) – Encourage ongoing abstinence and relapse prevention strategies.
Discharge Plan
- Discharge Disposition: Home with family support and structured daily routine
- Discharge Medications
- Sertraline 50mg PO daily – Continue for long-term depression management
- Hydroxyzine 25mg PO PRN (up to 3x daily) – As needed for anxiety
Discharge Instructions
- Continue practicing DBT skills (distress tolerance, emotional regulation, mindfulness).
- Engage in structured daily self-care routine (sleep hygiene, exercise, social engagement).
- Monitor for worsening mood, intrusive thoughts, or side effects from medications.
- Avoid alcohol and substances; continue relapse prevention plan.
- Contact crisis line immediately if suicidal thoughts return or if experiencing severe mood deterioration.
Follow-Up Appointments
- Psychiatry Visit: Dr. Emily Henshaw, Willow Behavioral Health – 18 March 2024 (for medication review and mood stabilization assessment)
- Therapy Appointment: Willow Counseling Center – 22 March 2024 (for ongoing psychotherapy and relapse prevention strategies)
Copies Sent To:
- Outpatient Psychiatrist: Dr. Emily Henshaw, Willow Behavioral Health
3. Sample Discharge Summary for Insurance Claims
Patient & Hospital Details
- Patient & Hospital Details
- Patient Name: John Doe
- Date of Birth: 10 June 1963 (61 years old)
- Medical Record Number (MRN): [987654]
- Date of Admission: 1 February 2025
- Date of Discharge: 7 February 2025
- Hospital Name & Unit: City General Hospital – Cardiology Unit
- Attending Physician: Dr. Robert Langley
- Billing Code: ICD-10
- I21.4 – Non-ST Elevation Myocardial Infarction (NSTEMI)
- I10 – Hypertension
- E78.5 – Hyperlipidemia
Diagnosis & Clinical Course
- Admission Diagnosis: Non-ST Elevation Myocardial Infarction (NSTEMI)
- Discharge Diagnosis: NSTEMI, managed medically
- Secondary Diagnoses: Hypertension, Hyperlipidemia
Hospital Stay Summary
- Consultations:
- Cardiology – Risk stratification, medication optimization
- Internal Medicine – Hypertension and lipid management
- Procedures:
- Cardiac catheterization – No significant coronary artery occlusion noted
- Echocardiogram – Preserved ejection fraction (EF), no wall motion abnormalities
- History of Present Illness (HPI):
- 60-year-old male with history of hypertension and hyperlipidemia presented with substernal chest pain radiating to left arm.
- Troponin peaked at 1.8 ng/mL, ECG showed nonspecific T-wave inversions.
- Diagnosed with NSTEMI and admitted for monitoring, risk assessment, and medical management.
- Brief Hospital Course:
- Managed with dual antiplatelet therapy (DAPT), beta-blocker, and high-intensity statin.
- No further chest pain during hospitalization.
- Cardiology recommended aggressive risk factor modification, medication adherence, and lifestyle changes.
Pending & Follow-Up Needs
- Pending Lab or Test Results:
- Lipid panel pending for follow-up evaluation.
- Immunizations Given During Admission: None
- Alerts & Special Considerations:
- High-risk for recurrent cardiovascular events – Strict adherence to medication and follow-up required.
- Monitor blood pressure closely due to recent medication adjustments.
Discharge Plan
- Discharge Disposition: Home with instructions for lifestyle modifications and self-monitoring
- Dietary Recommendations: Low-fat, heart-healthy diet with a focus on reducing saturated fats and sodium intake.
Discharge Medications
- Aspirin 100mg PO daily (antiplatelet therapy)
- Clopidogrel 75mg PO daily (antiplatelet therapy)
- Metoprolol succinate 50mg PO daily (beta-blocker for cardiac protection)
- Atorvastatin 80mg PO daily (high-intensity statin for lipid management)
- Lisinopril 5mg PO daily (ACE inhibitor for blood pressure and cardiac remodeling)
Discharge Instructions
- Avoid strenuous activity for one week; gradually resume physical activity based on tolerance.
- Monitor for chest pain, dizziness, shortness of breath, or signs of medication side effects—seek immediate medical attention if any occur.
- Strongly encouraged smoking cessation—referred to smoking cessation program.
- Adherence to all prescribed medications is essential to prevent future cardiac events.
Follow-Up Appointments
- Cardiology Follow-Up: Dr. Mark Reynolds, Cardiology Associates – 14 February 2024 (to review medication effectiveness and lipid panel results)
- Primary Care Physician (PCP): Dr. Susan Lee, Westview Clinic – 20 February 2024 (for ongoing hypertension and lipid management)
Copies Sent To:
- Insurance Provider: XYZ Health Insurance
- Primary Care Provider (PCP): Dr. Susan Lee, Westview Clinic
Manually completing discharge summaries can be time-consuming andand prone to missing key details, often leading to delayed handovers, follow-up issues, and ultimately, burnout. This is where Heidi, an AI-powered medical scribe, can help transform your process.
Enhancing Discharge Efficiency with Heidi
With Heidi, you can instantly generate structured discharge summaries. Whether you’re a hospital nurse finalizing a discharge or a GP reviewing a summary for follow-up care, Heidi helps automate documentation while maintaining accuracy and compliance. Here’s how it works:
- Transcribe: Start recording during discharge rounds or shift handovers, and Heidi automatically captures key details—diagnoses, treatments, medication changes, and follow-up plans—turning them into a structured summary.
- Customize: Select from common discharge summary formats—narrative, bullet-point, or problem-based—and let Heidi structure your notes automatically while ensuring full HIPAA, GDPR, and hospital compliance.
- Transform: Let Heidi auto-populate medication lists and referral details, ensuring that no crucial follow-up actions are missed—so GPs receive complete and accurate discharge information.
Heidi meets the highest global security and privacy standards for clinical documentation, trusted by over 100,000 healthcare professionals worldwide. By streamlining discharge summaries, Heidi helps you spend less time chasing missing details and more time delivering quality patient care.
Free Discharge Summary Templates
Hospital Discharge Summary Template
The general hospital discharge summary template is a versatile template that you can use to document discharges across various patient conditions. Optimized for use with Heidi, it can significantly optimize documentation time and ensure consistency in discharge summaries.
Mental Health Discharge Summary Template
This mental health discharge summary template is designed for psychologists to document the conclusion of a client’s therapy with a clear and structured approach. It includes sections for referral details, presenting issues, diagnosis, treatment summary, progress, clinical observations, risk assessment, and discharge plan.
Discharge Summary Template for Substance Abuse
This sample discharge summary template for substance abuse is designed by a substance abuse counselor to document a client's treatment journey and discharge plan with clarity and accuracy. It includes sections for client details, treatment summary, discharge reasons, follow-up care plans, medications, legal considerations, and client education.
Emergency Room Discharge Summary Template
Designed for fast-paced emergency settings, this emergency room discharge template is designed to help provide clear, structured, and comprehensive discharge instructions. It includes sections for diagnosis, test results, treatments administered, prescribed medications, return precautions, patient education, and follow-up care, ensuring patients fully understand their post-ER care.
FAQs about Discharge Summary Templates
How soon should a discharge summary be completed after patient discharge?
A discharge summary should ideally be completed on the day of discharge or within 24 hours to ensure timely communication with outpatient providers. Delays can lead to gaps in care, missed follow-ups, and medication errors, making prompt documentation critical.
Can a patient request a copy of their discharge summary?
Yes, patients have the right to request a copy of their discharge summary as part of their medical records. Hospitals typically provide this upon request, and in many cases, summaries are also shared automatically with primary care providers.
How long should it take to write a discharge summary?
Hospital discharge summaries generally take 30 minutes to 2 hours to write depending on various factors such as completeness of details and availability of clinicians to verify information, among others. With Heidi, writing hospital discharge summaries can take no more than a couple of minutes since it takes just a few clicks to complete. Learn more through our Heidi Guide on AI note-taking and document generation.