Discharge summary forms are an essential part of patients’ care in hospitals. However, physicians often have to deal with patients who require additional treatment after being discharged from the hospital.
In such cases, accurate discharge summaries must be provided as soon as possible so they can continue their treatments at home or elsewhere.
These forms ensure that patients receive quality care during the initial post-hospitalization period. In addition, they serve as the primary documents that communicate the patient’s care plan to the post-hospitalization healthcare team at home or in another hospital. This article provides a comprehensive guide on discharge summary forms, including the importance of completing a summary discharge form for patients and its general format.
Hospital Discharge Summary Form Examples
What is a Discharge Form?
The discharge summary form summarizes the patient’s care provided during hospitalization. In addition, it contains information about the patient’s condition at the time of discharge, medications given, and instructions for follow-up care. These forms play a significant role in ensuring patient safety post-hospitalization. They are the primary documents that communicate the patient’s care plan to their primary caregivers at home or in another care facility.
A physician can test the patient’s comprehension of the discharge summary form instructions during the process of discharge using a simple yet effective technique known as the “teach-back method.” This technique allows the doctor to ask the patient questions about the discharge form to assess how much they understand. This helps detect any significant gaps in understanding what require additional education.
Importance
Discharge summary forms are usually completed during a patient’s hospital stay and contain essential medical information about the care they received, including details about allergies, medications, and clinical findings. This document facilitates continuity of care for patients. It can be shared with other healthcare professionals involved in the patient’s ongoing treatment and care plan, as well as with other members of the patient’s healthcare team. The discharge summary form is also a legal document used in court cases and as evidence in litigation or compensation claims. The hospital archives completed forms to maintain patient medical records.
General Format of a Discharge Form
The format of a discharge summary form varies by country, region, or the type of healthcare facility in which the patient was admitted. However, generic forms include sections such as the demographic data, history, and findings of the disease; plans of the patient’s treatment; medication details; allergy information; adverse effects; patient instructions; and personal information of the healthcare provider.
This form should be straightforward and easy to read, with details organized in separate sections or subsections. Each section should be easily identifiable with clear headings and subheadings. The information must also be listed in chronological order for easier understanding.
The following are the main sections of a discharge summary form and the basic format to use:
Demographic
The first section of this form contains the basic demographic information of the patient, the healthcare provider, hospital details, and clinical details.
Typically, the demographics section will be structured as follows:
Patient’s details
The patient’s details include their name, date of birth, age, gender, race or ethnicity, occupation, marital status, identification number, address, and telephone number. This section also includes the patient’s next of kin or emergency contact’s full name, relationship to the patient, and contact details.
EXAMPLE
Name: Mary Hopkins
D.O.B: 16/06/1996
Gender: Female
Occupation: Teacher
Marital Status: Single
ID number: 26789056
Address: 4th avenue park road suites
Telephone number: 134568902
Next of Kin: Jennifer Wendy
Relationship: Mother
Contact details:145789023
General practitioner’s (GP) details
The primary healthcare provider (GP) works with the hospital and other specialists to provide care for the patient. Therefore, their name, telephone number, email address, and fax number should be mentioned in the form.
EXAMPLE
Name: Dr. Rachael Perker
Medical License Number: 45678
Contact Information: rachaelperker@staugustinehospital.com
Hospital details
Details about the specific hospital where the patient was admitted, such as its name, telephone number, and address, should be included in this part of the discharge summary form. Other important information to include in this section is the name of the discharging consultant, the name of the discharging hospital department, the date and time of admission and discharge, and the patient’s destination after discharge from the hospital.
EXAMPLE
Hospital name: St Augustine Mission Hospital
Address: 3345 New York
Telephone Number: +1234567890
Discharging consultant’s name: is Dr. Yusuf Rashid
Department: Accident and Emergency A/E
Date of admission: December 12, 2021
Time: 1200hrs
Discharge date: January 6, 2022
Clinical details
The second section of the discharge summary form typically contains a detailed summary of the disease history, findings, investigations, diagnoses, management, and complications.
The format for this section is as discussed below:
History of the disease
The first subsection should contain a detailed summary of the patient’s medical history or illness that led to their hospitalization. This should include essential details such as any previous admissions or procedures, past medical history, or family history of similar conditions. The patient’s main complaint should also be included in this section.
EXAMPLE
Mary Hopkins was admitted to St. Augustine Mission Hospital on December 12, 2021, in the Accident and Emergency ward following her sudden collapse at home that same day. The patient’s condition deteriorated rapidly when she could not breathe normally and had a rapid heartbeat.
Investigations
The second subsection should list all diagnostic tests conducted during the patient’s hospital stay, including their name, reference range, and results. In addition, results of imaging tests such as X-rays, CT scans, and MRI scans, as well as any pending investigations, should be included in this subsection.
EXAMPLE
The patient suffered a mild concussion and contusion on the right side of the head. The patient’s CT scan showed a mild subdural hematoma on the right side of the head, along with other pathologies. An assessment of the patient’s blood count revealed anemia with an average white and red cell count and a normal platelet count. In addition, the patient’s ESR and CRP levels were raised, and her ANA level was elevated.
Diagnosis
The third subsection should list the final diagnoses made by the hospital team and their corresponding ICD-10 code.
EXAMPLE
Mary Hopkins was diagnosed with a subdural hematoma on the right side of her head.
Management
The fourth subsection should outline the treatment plan implemented during the patient’s hospital stay. This includes all treatments administered during the patient’s hospitalization, including medications, procedures, and any diagnostic tests performed.
EXAMPLE
Before being admitted to the hospital for further evaluation and treatment, she was given instructions to take acetaminophen as needed for pain control and management, as well as a history of headaches.
Complications
Other important items to include in the clinical details are any complications or adverse effects that occur during treatment or as a result of the procedures used.
EXAMPLE
In her treatment, Mary Hopkins underwent a craniotomy and supratentorial decompression for an acute subdural hematoma. Unfortunately, she developed postoperative complications such as a subdural effusion and hydrocephalus, which required drainage by intravenous antibiotics and decreased the patient’s consciousness.
Procedures
This section contains information about the operations or procedures that the patient underwent during their stay in the hospital. In addition, the date of the operation or procedure, the specific procedure, any complications related to the procedure, the specific anesthesia used during procedures, and any related complications or adverse effects should also be outlined in this subsection.
EXAMPLE
Mary Hopkins underwent an MRI scan, a CT scan, and a bone radiograph to determine the cause of her throbbing headache. She was also given a lumbar puncture test (LP) to assess the level of spinal fluid in her brain and any neurological problems that might have occurred.
Plans for patient’s treatment
The third section of the discharge summary form contains plans for the patient’s management, medications given, any follow-up appointments that have been set up with other healthcare providers, and referrals made by the hospital. To ensure a smooth recovery, the clinician should document any actions they would like the patient’s general practitioner to perform after discharge.
EXAMPLE
Mary Hopkins was instructed to have a CT scan, an MRI scan, and a lumbar puncture test to determine the cause of her headaches. She was also given a detailed list of medications for a postoperative headache. After several days in the hospital, she was discharged and told to see a GP for any complications or follow-up treatments required.
Medication details
Primary healthcare specialists and experts require precise information to ensure patients’ safe transition. As such, it should include a list of all the prescribed medications upon discharge and any changes to the existing medications.
This group requires the following information:
Medication changes
Provide a pertinent history of changes to the patient’s medication during their inpatient stay. Make sure to include detailed reasons for the medication changes. This should include information on adverse reactions to specific drugs. Additionally, this section might discuss any medications that were put on hold at the time of discharge, the reason they were put on hold, and when the primary healthcare provider should think about reintroducing them.
EXAMPLE
The dosage of medicine X has been reduced from two tablets to one tablet each time.
Medication to take home
This subsection records the medications the patient will take after being discharged from the hospital. The record should include the name of the prescribed medicine, dosage and frequency, duration of treatment, and descriptions to help with compliance such as medication charts or medication management service through a carer, etc.
EXAMPLE
To manage her pain and headaches at home, Mary Hopkins was instructed to take acetaminophen.
Allergies and adverse effects
This section contains information about all allergies or adverse effects that the patient experienced. Details such as the allergen, reaction, date of reaction, and source of information should be detailed in this section of the discharge summary form.
EXAMPLE
There were no significant reported allergies or adverse effects to the drugs administered.
Instructions for the patient
The discharge summary form should also include a description of the patient’s stay, describing the relevant events from admission to discharge. It should include details such as the assessments and investigations that were performed, investigation results, diagnoses, procedures, treatment provided, and follow-up.
The physician should use patient-friendly language while providing this summary. The discharging clinician should also provide dietary instructions for the patient, therapy requirements, and rehabilitation instructions. Finally, it should also include a specific listing of appointment dates and times for medical follow-up.
EXAMPLE
The clot in her head was successfully removed through surgery, and she was discharged after a few days of recovery. She was given acetaminophen to control her pain and advised to follow up with a GP two weeks after discharge. The physician further recommended that she follow a low-salt diet for a quicker recovery process. She was also advised to continue with anti-inflammatory pain medication.
Contact information of the healthcare provider
The last section of a typical discharge summary form includes the contact information of the healthcare provider who completed the discharge form. The information to be provided in this section includes the healthcare provider’s full name, designation, grade, department, signature, and date the summary was completed.
EXAMPLE
Discharging consultant’s name: is Dr. Yusuf Rashid
MD, PHD
Department: Accident and Emergency A/E
Discharge date: January 6, 2022
Frequently Asked Questions
It can be defined as a “clinical report” prepared by healthcare professionals and specialists that outlines the details of the hospitalization of a patient. It summarizes everything that happened during the inpatient stay, including physical findings, laboratory test results, radiographic studies, medications, and other relevant details.
Yes. Any information exchanged between patients and doctors or other healthcare providers is confidential, and as such, it should not be released to any third party without the patient’s consent.
A duly completed and effective discharge summary form must include six essential components, namely: the reason for hospitalization, diagnoses or key findings; the patient’s discharge condition, procedures done, and treatment administered; instructions for patients and caregivers as appropriate, and the signature of the physician who treated the patient.
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