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Isaac K S Ng, Daniel Tung, Trisha Seet, Ka Shing Yow, Karis L E Chan, Desmond B Teo, Chun En Chua, How to write a good discharge summary: a primer for junior physicians, Postgraduate Medical Journal, 2025;, qgaf020, https://doi.org/10.1093/postmj/qgaf020
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Abstract
A discharge summary is an important clinical document that summarizes a patient’s clinical information and relevant events that occurred during hospitalization. It serves as a detailed handover of the patient’s most recent and updated medical case records to general practitioners, who continue longitudinal follow-up with patients in the community and future medical care providers. A copy of the redacted/abbreviated form of the discharge summary is also usually given to patients and their caregivers so that important information, such as diagnoses, medication changes, return advice, and follow-up plans, is clearly documented. However, in reality, as discharge summaries are often written by junior physicians who may be inexperienced or have lacked medical training in this area, clinical audits often reveal poorly written discharge summaries that are unclear, inaccurate, or lack important details. Therefore, in this article, we sought to develop a simple “DISCHARGED” framework that outlines the important components of the discharge summary that we derived from a systematic search of relevant literature and further discuss several pedagogical strategies for training and assessing discharge summary writing.
Introduction
A discharge summary is an important clinical documentation that accurately and succinctly describes the patient’s medical history, diagnoses, treatment and follow-up plans during hospital admission [1]. It serves to facilitate transition of care from hospital-to-community [2], by providing up-to-date medical records and actionable items for follow-up in primary or ambulatory care settings [3]. Patient copies of redacted discharge summaries should be provided to educate them on diagnosed conditions, post-discharge instructions, medication changes and follow-up plans [4, 5]. However, as discharge summaries are typically written by junior physicians, who are often inexperienced and lack formal training in this area [2], numerous clinical audits have found significant deficiencies in terms of accuracies, completeness, and timeliness of discharge summaries in real-world practice [6]. This is an important issue as poor quality discharge summaries can adversely affect patient safety and outcomes, leading to increased readmission rates, medical errors, and delayed or missed outpatient appointments [6–8]. While the recent shift of medical records-keeping to electronic health systems have improved the timeliness of discharge summary transfer from hospital-to-primary care [6], there remains an urgent need for pedagogical and workplace-based interventions to improve the quality of written discharge summaries.
In this article, we performed a literature review to evaluate the essential components of a high-quality discharge summary and developed a practical “DISCHARGED” mnemonic framework that junior physicians may adopt for use in their routine clinical practice. In addition, we discuss several pedagogical strategies that may help improve the standards of discharge summary writing.
Essential components of a high-quality discharge summary
A PubMed search of relevant literature published from 1 January 2015 to 19 October 2024 over the past 10 years was undertaken to identify the key components that underpin a high-quality discharge summary. The search strategy adopted was as follows: “discharge summary” (title/abstract) OR “discharge summaries” (title/abstract) AND “quality” (title/abstract) OR “standard” (title/abstract). Only primary research, including clinical audits and quality improvement projects, related to quality assessment or indicators of physician-written hospital discharge summaries were included. Secondary forms of research, unavailable texts, articles not written in English, or absence of specified quality indicators/components of a high-quality discharge summary were excluded. A total of 377 articles were retrieved, and 62 articles were ultimately selected for use based on the above criteria.
A total of 20 essential categories of information (patient demographics, clinical alerts, past medical/surgical history, admission information/history of presenting complaint, physical examination findings, diagnoses/problem lists, severity/complications, precipitants/triggers/causes identified, investigations, treatments/interventions received and clinical response, functional/cognitive issues, psychosocial issues, dietary requirements, relevant discharge information, discharge instructions, medication list and changes, goals of care discussion (if applicable), follow-up plans, information about discharge summary writers, and primary care healthcare provider details) relevant to a high-quality discharge summary were summarized in Table 1.
Identified essential components of high-quality discharge summaries retrieved from literature review of relevant studies from 2015–2024.
| . | Component of high-quality discharge summary (and referenced studies) . |
|---|---|
| 1 | Patient demographics (e.g. name, age/date-of-birth, gender, address, patient identification number) [8–30] |
| 2 | Clinical alerts (e.g. drug allergy, adverse events, special risks/precautions to be aware of) [3, 10, 12, 15–17, 19, 22, 23, 25, 26, 28, 30–32] |
| 3 | Past medical/surgical history [4, 6, 8, 12–15, 17–20, 22, 24, 25, 27, 31, 33–39] |
| 4 | Admission information (e.g. date of admission, history of presenting complaint/reason for admission, source of referral to hospital, method of admission) [3, 4, 6, 8, 10–26, 28–49] |
| 5 | Pertinent physical examination findings [4, 14, 15, 22, 24, 25, 28, 32, 35, 36, 40, 41, 44, 45, 48, 50, 51] |
| 6 | Main diagnoses/ICD-10 disease codes/problem lists [3, 4, 6, 8–32, 34–38, 40–61] |
| 7 | Severity/complications [8, 19, 24, 26, 34, 58, 60] |
| 8 | Identified precipitants/triggers/cause of disease or exacerbations [18, 19, 24, 43, 47, 55, 58] |
| 9 | Key investigations performed [3, 6, 8, 10–19, 21–25, 27–30, 32–38, 40–45, 47–50, 52–57, 62] |
| 10 | Relevant treatment, interventions (surgeries/procedures), subspecialty consultants, and patient’s clinical progress/response [3, 4, 6, 8–19, 21–25, 27–38, 40–45, 47–51, 53–57] |
| 11 | Functional (current and premorbid function, physiotherapist/occupational therapist review, rehabilitation requirements and goals) and cognitive issues [4–6, 8, 16, 18, 19, 25, 27, 33–36, 40, 44, 45, 47, 50, 53, 54, 63] |
| 12 | Psychosocial issues (e.g. social/caregiving set-up, smoking, alcohol, psychological conditions) [4, 19, 25, 27, 28, 34, 36–38, 40, 41, 44, 53, 54] |
| 13 | Dietary requirements/intervention [4, 16, 24, 25] |
| 14 | Relevant discharge information (e.g. date of discharge, discharge specialty, primary team consultant-in-charge, discharge condition (e.g. improved/stable/deteriorating condition or death (coroner/non-coroner) and cause of death), discharge disposition (home, step-down care, etc.), and circumstances (routine discharge or discharge against medical advice) [3, 4, 6, 8, 10–13, 15, 16, 18, 19, 21–28, 30–33, 36, 41, 43–47, 60] |
| 15 | Post-discharge instructions/relevant information for patient/caregivers (e.g. return or care advice, health promotion, educational information, contact information) [3, 4, 12, 15, 16, 19, 22–25, 28, 30, 31, 40, 41, 44, 45, 47–50, 58, 63] |
| 16 | Updated medication list and changes made (including rationale) [3, 6, 8, 10–13, 15, 17, 19–21, 23–41, 43–50, 52–54, 57–60, 62–65] |
| 17 | Documentation of goals of care (e.g. established limitations of treatment/intervention) [19, 22, 25, 27, 28, 36, 44, 45, 53, 54] |
| 18 | Follow-up plans (at primary care and hospital outpatient clinics; including pending investigations to trace) [4, 6, 8–13, 15–19, 21–24, 26–32, 34–50, 52, 55–58, 60, 62, 63] |
| 19 | Information of discharge summary writer (e.g. name, medical registration number, job title/clinical grade, contact information) and senior personnel performing counter-sign (if applicable) [8–10, 12, 15, 16, 20, 21, 23, 24, 27–30, 41, 45, 47, 52, 56] |
| 20 | Primary care healthcare provider details (e.g. name, practice address) [10, 13, 16, 18, 19, 21, 25–27, 32, 47, 55] |
| . | Component of high-quality discharge summary (and referenced studies) . |
|---|---|
| 1 | Patient demographics (e.g. name, age/date-of-birth, gender, address, patient identification number) [8–30] |
| 2 | Clinical alerts (e.g. drug allergy, adverse events, special risks/precautions to be aware of) [3, 10, 12, 15–17, 19, 22, 23, 25, 26, 28, 30–32] |
| 3 | Past medical/surgical history [4, 6, 8, 12–15, 17–20, 22, 24, 25, 27, 31, 33–39] |
| 4 | Admission information (e.g. date of admission, history of presenting complaint/reason for admission, source of referral to hospital, method of admission) [3, 4, 6, 8, 10–26, 28–49] |
| 5 | Pertinent physical examination findings [4, 14, 15, 22, 24, 25, 28, 32, 35, 36, 40, 41, 44, 45, 48, 50, 51] |
| 6 | Main diagnoses/ICD-10 disease codes/problem lists [3, 4, 6, 8–32, 34–38, 40–61] |
| 7 | Severity/complications [8, 19, 24, 26, 34, 58, 60] |
| 8 | Identified precipitants/triggers/cause of disease or exacerbations [18, 19, 24, 43, 47, 55, 58] |
| 9 | Key investigations performed [3, 6, 8, 10–19, 21–25, 27–30, 32–38, 40–45, 47–50, 52–57, 62] |
| 10 | Relevant treatment, interventions (surgeries/procedures), subspecialty consultants, and patient’s clinical progress/response [3, 4, 6, 8–19, 21–25, 27–38, 40–45, 47–51, 53–57] |
| 11 | Functional (current and premorbid function, physiotherapist/occupational therapist review, rehabilitation requirements and goals) and cognitive issues [4–6, 8, 16, 18, 19, 25, 27, 33–36, 40, 44, 45, 47, 50, 53, 54, 63] |
| 12 | Psychosocial issues (e.g. social/caregiving set-up, smoking, alcohol, psychological conditions) [4, 19, 25, 27, 28, 34, 36–38, 40, 41, 44, 53, 54] |
| 13 | Dietary requirements/intervention [4, 16, 24, 25] |
| 14 | Relevant discharge information (e.g. date of discharge, discharge specialty, primary team consultant-in-charge, discharge condition (e.g. improved/stable/deteriorating condition or death (coroner/non-coroner) and cause of death), discharge disposition (home, step-down care, etc.), and circumstances (routine discharge or discharge against medical advice) [3, 4, 6, 8, 10–13, 15, 16, 18, 19, 21–28, 30–33, 36, 41, 43–47, 60] |
| 15 | Post-discharge instructions/relevant information for patient/caregivers (e.g. return or care advice, health promotion, educational information, contact information) [3, 4, 12, 15, 16, 19, 22–25, 28, 30, 31, 40, 41, 44, 45, 47–50, 58, 63] |
| 16 | Updated medication list and changes made (including rationale) [3, 6, 8, 10–13, 15, 17, 19–21, 23–41, 43–50, 52–54, 57–60, 62–65] |
| 17 | Documentation of goals of care (e.g. established limitations of treatment/intervention) [19, 22, 25, 27, 28, 36, 44, 45, 53, 54] |
| 18 | Follow-up plans (at primary care and hospital outpatient clinics; including pending investigations to trace) [4, 6, 8–13, 15–19, 21–24, 26–32, 34–50, 52, 55–58, 60, 62, 63] |
| 19 | Information of discharge summary writer (e.g. name, medical registration number, job title/clinical grade, contact information) and senior personnel performing counter-sign (if applicable) [8–10, 12, 15, 16, 20, 21, 23, 24, 27–30, 41, 45, 47, 52, 56] |
| 20 | Primary care healthcare provider details (e.g. name, practice address) [10, 13, 16, 18, 19, 21, 25–27, 32, 47, 55] |
Identified essential components of high-quality discharge summaries retrieved from literature review of relevant studies from 2015–2024.
| . | Component of high-quality discharge summary (and referenced studies) . |
|---|---|
| 1 | Patient demographics (e.g. name, age/date-of-birth, gender, address, patient identification number) [8–30] |
| 2 | Clinical alerts (e.g. drug allergy, adverse events, special risks/precautions to be aware of) [3, 10, 12, 15–17, 19, 22, 23, 25, 26, 28, 30–32] |
| 3 | Past medical/surgical history [4, 6, 8, 12–15, 17–20, 22, 24, 25, 27, 31, 33–39] |
| 4 | Admission information (e.g. date of admission, history of presenting complaint/reason for admission, source of referral to hospital, method of admission) [3, 4, 6, 8, 10–26, 28–49] |
| 5 | Pertinent physical examination findings [4, 14, 15, 22, 24, 25, 28, 32, 35, 36, 40, 41, 44, 45, 48, 50, 51] |
| 6 | Main diagnoses/ICD-10 disease codes/problem lists [3, 4, 6, 8–32, 34–38, 40–61] |
| 7 | Severity/complications [8, 19, 24, 26, 34, 58, 60] |
| 8 | Identified precipitants/triggers/cause of disease or exacerbations [18, 19, 24, 43, 47, 55, 58] |
| 9 | Key investigations performed [3, 6, 8, 10–19, 21–25, 27–30, 32–38, 40–45, 47–50, 52–57, 62] |
| 10 | Relevant treatment, interventions (surgeries/procedures), subspecialty consultants, and patient’s clinical progress/response [3, 4, 6, 8–19, 21–25, 27–38, 40–45, 47–51, 53–57] |
| 11 | Functional (current and premorbid function, physiotherapist/occupational therapist review, rehabilitation requirements and goals) and cognitive issues [4–6, 8, 16, 18, 19, 25, 27, 33–36, 40, 44, 45, 47, 50, 53, 54, 63] |
| 12 | Psychosocial issues (e.g. social/caregiving set-up, smoking, alcohol, psychological conditions) [4, 19, 25, 27, 28, 34, 36–38, 40, 41, 44, 53, 54] |
| 13 | Dietary requirements/intervention [4, 16, 24, 25] |
| 14 | Relevant discharge information (e.g. date of discharge, discharge specialty, primary team consultant-in-charge, discharge condition (e.g. improved/stable/deteriorating condition or death (coroner/non-coroner) and cause of death), discharge disposition (home, step-down care, etc.), and circumstances (routine discharge or discharge against medical advice) [3, 4, 6, 8, 10–13, 15, 16, 18, 19, 21–28, 30–33, 36, 41, 43–47, 60] |
| 15 | Post-discharge instructions/relevant information for patient/caregivers (e.g. return or care advice, health promotion, educational information, contact information) [3, 4, 12, 15, 16, 19, 22–25, 28, 30, 31, 40, 41, 44, 45, 47–50, 58, 63] |
| 16 | Updated medication list and changes made (including rationale) [3, 6, 8, 10–13, 15, 17, 19–21, 23–41, 43–50, 52–54, 57–60, 62–65] |
| 17 | Documentation of goals of care (e.g. established limitations of treatment/intervention) [19, 22, 25, 27, 28, 36, 44, 45, 53, 54] |
| 18 | Follow-up plans (at primary care and hospital outpatient clinics; including pending investigations to trace) [4, 6, 8–13, 15–19, 21–24, 26–32, 34–50, 52, 55–58, 60, 62, 63] |
| 19 | Information of discharge summary writer (e.g. name, medical registration number, job title/clinical grade, contact information) and senior personnel performing counter-sign (if applicable) [8–10, 12, 15, 16, 20, 21, 23, 24, 27–30, 41, 45, 47, 52, 56] |
| 20 | Primary care healthcare provider details (e.g. name, practice address) [10, 13, 16, 18, 19, 21, 25–27, 32, 47, 55] |
| . | Component of high-quality discharge summary (and referenced studies) . |
|---|---|
| 1 | Patient demographics (e.g. name, age/date-of-birth, gender, address, patient identification number) [8–30] |
| 2 | Clinical alerts (e.g. drug allergy, adverse events, special risks/precautions to be aware of) [3, 10, 12, 15–17, 19, 22, 23, 25, 26, 28, 30–32] |
| 3 | Past medical/surgical history [4, 6, 8, 12–15, 17–20, 22, 24, 25, 27, 31, 33–39] |
| 4 | Admission information (e.g. date of admission, history of presenting complaint/reason for admission, source of referral to hospital, method of admission) [3, 4, 6, 8, 10–26, 28–49] |
| 5 | Pertinent physical examination findings [4, 14, 15, 22, 24, 25, 28, 32, 35, 36, 40, 41, 44, 45, 48, 50, 51] |
| 6 | Main diagnoses/ICD-10 disease codes/problem lists [3, 4, 6, 8–32, 34–38, 40–61] |
| 7 | Severity/complications [8, 19, 24, 26, 34, 58, 60] |
| 8 | Identified precipitants/triggers/cause of disease or exacerbations [18, 19, 24, 43, 47, 55, 58] |
| 9 | Key investigations performed [3, 6, 8, 10–19, 21–25, 27–30, 32–38, 40–45, 47–50, 52–57, 62] |
| 10 | Relevant treatment, interventions (surgeries/procedures), subspecialty consultants, and patient’s clinical progress/response [3, 4, 6, 8–19, 21–25, 27–38, 40–45, 47–51, 53–57] |
| 11 | Functional (current and premorbid function, physiotherapist/occupational therapist review, rehabilitation requirements and goals) and cognitive issues [4–6, 8, 16, 18, 19, 25, 27, 33–36, 40, 44, 45, 47, 50, 53, 54, 63] |
| 12 | Psychosocial issues (e.g. social/caregiving set-up, smoking, alcohol, psychological conditions) [4, 19, 25, 27, 28, 34, 36–38, 40, 41, 44, 53, 54] |
| 13 | Dietary requirements/intervention [4, 16, 24, 25] |
| 14 | Relevant discharge information (e.g. date of discharge, discharge specialty, primary team consultant-in-charge, discharge condition (e.g. improved/stable/deteriorating condition or death (coroner/non-coroner) and cause of death), discharge disposition (home, step-down care, etc.), and circumstances (routine discharge or discharge against medical advice) [3, 4, 6, 8, 10–13, 15, 16, 18, 19, 21–28, 30–33, 36, 41, 43–47, 60] |
| 15 | Post-discharge instructions/relevant information for patient/caregivers (e.g. return or care advice, health promotion, educational information, contact information) [3, 4, 12, 15, 16, 19, 22–25, 28, 30, 31, 40, 41, 44, 45, 47–50, 58, 63] |
| 16 | Updated medication list and changes made (including rationale) [3, 6, 8, 10–13, 15, 17, 19–21, 23–41, 43–50, 52–54, 57–60, 62–65] |
| 17 | Documentation of goals of care (e.g. established limitations of treatment/intervention) [19, 22, 25, 27, 28, 36, 44, 45, 53, 54] |
| 18 | Follow-up plans (at primary care and hospital outpatient clinics; including pending investigations to trace) [4, 6, 8–13, 15–19, 21–24, 26–32, 34–50, 52, 55–58, 60, 62, 63] |
| 19 | Information of discharge summary writer (e.g. name, medical registration number, job title/clinical grade, contact information) and senior personnel performing counter-sign (if applicable) [8–10, 12, 15, 16, 20, 21, 23, 24, 27–30, 41, 45, 47, 52, 56] |
| 20 | Primary care healthcare provider details (e.g. name, practice address) [10, 13, 16, 18, 19, 21, 25–27, 32, 47, 55] |
Although beyond the scope of the present discussion, there are other unique subspecialty-specific clinical information that could warrant inclusion in the discharge summary, for instance, wound/ostomy/drain management plans for surgical patients [4], anthropometric parameters for pediatric patients [9], comprehensive geriatric assessments for older adults [10, 33] or suicide/risk assessments for patients with mental health issues [40].
Besides having complete and accurate content in discharge summaries, the documented information must be adequately succinct [11], and clearly conveyed with minimal use of non-standard abbreviations [11, 31, 66], and jargons (especially for patient copy of the discharge summaries) [11, 41].
“DISCHARGED” mnemonic framework for writing a comprehensive discharge summary
On the basis of the previously identified categories of essential information for a high-quality discharge summary, we developed a practical “DISCHARGED” mnemonic framework (Table 2) for use in writing discharge summaries in routine practice.
The “DISCHARGED” mnemonic framework for writing a high-quality discharge summary.
| Clinical vignette: Mr Joseph Tan is a 75-year-old Chinese male, with background of diabetes mellitus, hypertension, ischemic heart disease, GOLD E COPD, was recently admitted for community-acquired pneumonia complicated by infective exacerbation of COPD. He was treated with antibiotics for pneumonia and nebulized short-acting bronchodilators and short-course steroids for COPD exacerbation. His inhaler technique was also reviewed by the respiratory subspecialty nurse. During admission, he was also noted to have functional decline requiring physiotherapist review, and recurrent postural giddiness due to postural hypotension from dehydrated state requiring intravenous fluids initially. After a 4-day admission, patient is now ready to be discharged home, with planned follow-up with his GP in 6–8 weeks with repeat chest X-ray to check for resolution of consolidative changes. | |
| Component | Practical example |
| Demographic information | Joseph Tan 75-year-old Chinese gentleman Identification number XXXX Home address: 55 Lavender Street, Postal Code: 12345A |
| Important alerts | Drug allergies: co-trimoxazole (allergic reaction: rash) Adverse drug reactions: NSAIDs intolerance Contact precautions (Methicillin-Resistant Staphylococcus Aureus carrier) |
| Social set-up and premorbid function | Relevant social history Former smoker of 60 pack-years, non-alcohol drinker Retired cab driver Stays with wife and helper Has 2 children (1 son and 1 daughter) who stay apart but visits regularly Premorbid functional status ADL-independent, home ambulant with furniture cruising, and community ambulant with walking stick |
| Comprehensive past medical/surgical history and medication records | Medical history 1. Diabetes mellitus—latest HbA1c 6.5%, on oral hypoglycemic agents (metformin and glipizide) 2. Hypertension 3. Ischemic heart disease—had previous NSTEMI 10 years ago, with coronary angiogram showing single vessel disease (mid-left anterior descending artery (LAD) 80% stenosis), s/p percutaneous coronary intervention to culprit mid-LAD lesion; latest transthoracic echocardiogram 2 years ago shows preserved left ventricular ejection function 55% 4. Gold E COPD—on triple inhaler (Trelegy), may require long-term oxygen therapy in the near future Surgical history 1. Previous cholecystitis 10 years ago s/p laparoscopic cholecystectomy |
| History of presenting complaint and physical examination findings | Patient was admitted on D/MM/YYYY as a referral to the ED from his GP for breathlessness, productive cough, fever, and low oxygen saturations. Clinical history 1. Dyspnea of 3-day duration - Worse on exertion but also present at rest - Not worse on lying flat (orthopnea), no breathlessness that wakes him up from sleep (paroxysmal nocturnal dyspnea) - Intermittent in nature, feels getting slightly worse - Associated with productive cough of greenish phlegm - No sore throat or rhinorrhea - Not sure about presence of wheezing—did not notice noisy breathing - No chest pain - Has tactile fever, but did not measure temperature at home - No chills/rigors - No night sweats - No sick contacts 2. Giddiness of 1-day duration - Started feeling giddy since this morning - Non-vertiginous in nature - Worse on getting up from a lying/seated position (postural) - No headaches/nausea/vomiting - No other neurological symptoms such as numbness/weakness, speech or swallowing impairment, visual disturbances - No otological symptoms - Has not been eating or drinking much for past few days but no weight loss No other systemic complaints such as abdominal pain, urinary symptoms, or nausea/vomiting/diarrhea. Physical examination Vital signs on arrival in ED: T38.3, blood pressure 110/75 mmHg, heart rate 108/min, respiratory rate 28/min, oxygen saturations 87% on room air Postural blood pressure measurement—significant drop from 110/75 to 85/55 mmHg Alert and oriented, but lethargic looking Clinically dehydrated No cervical lymphadenopathy Heart sounds dual with no audible murmurs Lungs—presence of right lower zone crepitations, with bilateral end-expiratory rhonchi Abdomen soft and non-tender Neurological examination is unremarkable |
| Assessment and clinical course (include problem lists, differential considerations, relevant investigations, management, and disease progress/clinical response) | Clinical problem list 1. Community acquired pneumonia, complicated by infective exacerbation of COPD - Presented with 3-day history of breathlessness, productive cough (of greenish phlegm) and fever (Tmax 38.3 on arrival), with low oxygen saturations (87% on room air on arrival); clinical examination reveals right lower zone crepitations, bilateral end-expiratory rhonchi - Background of GOLD E COPD on triple inhaler therapy (on average 3 hospitalizations for exacerbations every year) - White cell count on arrival – 13 × 109/L (with neutrophilia) - Chest X ray on arrival shows right-lower zone consolidation - Patient was given antibiotics (Augmentin for 7 days, Azithromycin for 3 days) for community acquired pneumonia, nebulized bronchodilator therapy until wheezing/symptoms improved and steroids (prednisolone for 5 days) for flare of COPD. Patient’s inhaler technique was also assessed by respiratory subspecialty nurse and deemed to be good. Patient made a good clinical recovery, with symptomatic improvement, resolution of fever, and could wean off supplemental oxygen (2 L nasal prongs) by third day of admission. Complicated by a) KDIGO 1 AKI due to intravascular depletion (prerenal cause) - Baseline Creatinine levels 60–80 mmol/L > 110 mmol/L on arrival > > peaked 132 mmol/L > > 82 mmol/L on discharge - Given intravenous fluids in view of hypovolemic state with down-trending creatinine and eventual resolution of AKI on discharge b) Symptomatic postural hypotension - Presented with 1-day history of postural giddiness - Significant postural blood pressure drop noted in the first 2 days of admission - Subsequently, resolved with intravenous fluids c) Functional decline - Premorbidly ADL-independent, home-ambulant with furniture cruise, community-ambulant with walking stick - Noted during initial physiotherapy assessment that patient had reduced effort tolerance, and was slightly unsteady, requiring hand-hold assistance in short-distance ambulation - Subsequently, patient made significant improvements over next 3 physiotherapy sessions, and was near premorbid function by discharge 2. Hypoglycemic episode due to poor oral intake, background of diabetes mellitus on oral hypoglycemic agents - Resolved with oral dextrose-containing drink - Reduced glipizide dose from 5 to 2.5 mg BD |
| Record of medication changes | To complete 3 more days of oral Augmentin 625 mg BD, and 1 more day of oral prednisolone 30 mg OM on discharge. Changes to chronic medications: oral glipizide dose reduced from 5 mg BD to 2.5 mg BD in view of hypoglycemia episode. |
| Goals of care documentation | Discussed with patient and family this admission—decided for maximum non-invasive ventilation treatment, but not for intubation/mechanical ventilation, chest compressions, or intensive care unit transfer in the event of cardiac/respiratory arrest. |
| Expected follow-up plans and post-discharge instructions | To follow-up with patient’s GP in 6-8 weeks’ time for 1) continued follow-up of chronic conditions and titration of medications, 2) repeat chest X-ray for resolution of consolidative changes and for continued follow-up of chronic conditions. Patient is advised to be compliant to inhaler use, and keep well-hydrated/get up from seated/lying position slowly in view of postural hypotension. |
| Discharge information | Patient was discharged well and stable on DD/MM/YYYY from Department of General Medicine, XXX hospital back to his home. His condition was significantly improved at point of discharge. Consultant-in-charge: Dr. ABC Discharge summary completed by: Dr. DEF, MP12345A, House Officer. Discharge summary counter-signed by: Dr. GHI, M56789B, Registrar. Hospital contact information: 12345678. |
| Clinical vignette: Mr Joseph Tan is a 75-year-old Chinese male, with background of diabetes mellitus, hypertension, ischemic heart disease, GOLD E COPD, was recently admitted for community-acquired pneumonia complicated by infective exacerbation of COPD. He was treated with antibiotics for pneumonia and nebulized short-acting bronchodilators and short-course steroids for COPD exacerbation. His inhaler technique was also reviewed by the respiratory subspecialty nurse. During admission, he was also noted to have functional decline requiring physiotherapist review, and recurrent postural giddiness due to postural hypotension from dehydrated state requiring intravenous fluids initially. After a 4-day admission, patient is now ready to be discharged home, with planned follow-up with his GP in 6–8 weeks with repeat chest X-ray to check for resolution of consolidative changes. | |
| Component | Practical example |
| Demographic information | Joseph Tan 75-year-old Chinese gentleman Identification number XXXX Home address: 55 Lavender Street, Postal Code: 12345A |
| Important alerts | Drug allergies: co-trimoxazole (allergic reaction: rash) Adverse drug reactions: NSAIDs intolerance Contact precautions (Methicillin-Resistant Staphylococcus Aureus carrier) |
| Social set-up and premorbid function | Relevant social history Former smoker of 60 pack-years, non-alcohol drinker Retired cab driver Stays with wife and helper Has 2 children (1 son and 1 daughter) who stay apart but visits regularly Premorbid functional status ADL-independent, home ambulant with furniture cruising, and community ambulant with walking stick |
| Comprehensive past medical/surgical history and medication records | Medical history 1. Diabetes mellitus—latest HbA1c 6.5%, on oral hypoglycemic agents (metformin and glipizide) 2. Hypertension 3. Ischemic heart disease—had previous NSTEMI 10 years ago, with coronary angiogram showing single vessel disease (mid-left anterior descending artery (LAD) 80% stenosis), s/p percutaneous coronary intervention to culprit mid-LAD lesion; latest transthoracic echocardiogram 2 years ago shows preserved left ventricular ejection function 55% 4. Gold E COPD—on triple inhaler (Trelegy), may require long-term oxygen therapy in the near future Surgical history 1. Previous cholecystitis 10 years ago s/p laparoscopic cholecystectomy |
| History of presenting complaint and physical examination findings | Patient was admitted on D/MM/YYYY as a referral to the ED from his GP for breathlessness, productive cough, fever, and low oxygen saturations. Clinical history 1. Dyspnea of 3-day duration - Worse on exertion but also present at rest - Not worse on lying flat (orthopnea), no breathlessness that wakes him up from sleep (paroxysmal nocturnal dyspnea) - Intermittent in nature, feels getting slightly worse - Associated with productive cough of greenish phlegm - No sore throat or rhinorrhea - Not sure about presence of wheezing—did not notice noisy breathing - No chest pain - Has tactile fever, but did not measure temperature at home - No chills/rigors - No night sweats - No sick contacts 2. Giddiness of 1-day duration - Started feeling giddy since this morning - Non-vertiginous in nature - Worse on getting up from a lying/seated position (postural) - No headaches/nausea/vomiting - No other neurological symptoms such as numbness/weakness, speech or swallowing impairment, visual disturbances - No otological symptoms - Has not been eating or drinking much for past few days but no weight loss No other systemic complaints such as abdominal pain, urinary symptoms, or nausea/vomiting/diarrhea. Physical examination Vital signs on arrival in ED: T38.3, blood pressure 110/75 mmHg, heart rate 108/min, respiratory rate 28/min, oxygen saturations 87% on room air Postural blood pressure measurement—significant drop from 110/75 to 85/55 mmHg Alert and oriented, but lethargic looking Clinically dehydrated No cervical lymphadenopathy Heart sounds dual with no audible murmurs Lungs—presence of right lower zone crepitations, with bilateral end-expiratory rhonchi Abdomen soft and non-tender Neurological examination is unremarkable |
| Assessment and clinical course (include problem lists, differential considerations, relevant investigations, management, and disease progress/clinical response) | Clinical problem list 1. Community acquired pneumonia, complicated by infective exacerbation of COPD - Presented with 3-day history of breathlessness, productive cough (of greenish phlegm) and fever (Tmax 38.3 on arrival), with low oxygen saturations (87% on room air on arrival); clinical examination reveals right lower zone crepitations, bilateral end-expiratory rhonchi - Background of GOLD E COPD on triple inhaler therapy (on average 3 hospitalizations for exacerbations every year) - White cell count on arrival – 13 × 109/L (with neutrophilia) - Chest X ray on arrival shows right-lower zone consolidation - Patient was given antibiotics (Augmentin for 7 days, Azithromycin for 3 days) for community acquired pneumonia, nebulized bronchodilator therapy until wheezing/symptoms improved and steroids (prednisolone for 5 days) for flare of COPD. Patient’s inhaler technique was also assessed by respiratory subspecialty nurse and deemed to be good. Patient made a good clinical recovery, with symptomatic improvement, resolution of fever, and could wean off supplemental oxygen (2 L nasal prongs) by third day of admission. Complicated by a) KDIGO 1 AKI due to intravascular depletion (prerenal cause) - Baseline Creatinine levels 60–80 mmol/L > 110 mmol/L on arrival > > peaked 132 mmol/L > > 82 mmol/L on discharge - Given intravenous fluids in view of hypovolemic state with down-trending creatinine and eventual resolution of AKI on discharge b) Symptomatic postural hypotension - Presented with 1-day history of postural giddiness - Significant postural blood pressure drop noted in the first 2 days of admission - Subsequently, resolved with intravenous fluids c) Functional decline - Premorbidly ADL-independent, home-ambulant with furniture cruise, community-ambulant with walking stick - Noted during initial physiotherapy assessment that patient had reduced effort tolerance, and was slightly unsteady, requiring hand-hold assistance in short-distance ambulation - Subsequently, patient made significant improvements over next 3 physiotherapy sessions, and was near premorbid function by discharge 2. Hypoglycemic episode due to poor oral intake, background of diabetes mellitus on oral hypoglycemic agents - Resolved with oral dextrose-containing drink - Reduced glipizide dose from 5 to 2.5 mg BD |
| Record of medication changes | To complete 3 more days of oral Augmentin 625 mg BD, and 1 more day of oral prednisolone 30 mg OM on discharge. Changes to chronic medications: oral glipizide dose reduced from 5 mg BD to 2.5 mg BD in view of hypoglycemia episode. |
| Goals of care documentation | Discussed with patient and family this admission—decided for maximum non-invasive ventilation treatment, but not for intubation/mechanical ventilation, chest compressions, or intensive care unit transfer in the event of cardiac/respiratory arrest. |
| Expected follow-up plans and post-discharge instructions | To follow-up with patient’s GP in 6-8 weeks’ time for 1) continued follow-up of chronic conditions and titration of medications, 2) repeat chest X-ray for resolution of consolidative changes and for continued follow-up of chronic conditions. Patient is advised to be compliant to inhaler use, and keep well-hydrated/get up from seated/lying position slowly in view of postural hypotension. |
| Discharge information | Patient was discharged well and stable on DD/MM/YYYY from Department of General Medicine, XXX hospital back to his home. His condition was significantly improved at point of discharge. Consultant-in-charge: Dr. ABC Discharge summary completed by: Dr. DEF, MP12345A, House Officer. Discharge summary counter-signed by: Dr. GHI, M56789B, Registrar. Hospital contact information: 12345678. |
The “DISCHARGED” mnemonic framework for writing a high-quality discharge summary.
| Clinical vignette: Mr Joseph Tan is a 75-year-old Chinese male, with background of diabetes mellitus, hypertension, ischemic heart disease, GOLD E COPD, was recently admitted for community-acquired pneumonia complicated by infective exacerbation of COPD. He was treated with antibiotics for pneumonia and nebulized short-acting bronchodilators and short-course steroids for COPD exacerbation. His inhaler technique was also reviewed by the respiratory subspecialty nurse. During admission, he was also noted to have functional decline requiring physiotherapist review, and recurrent postural giddiness due to postural hypotension from dehydrated state requiring intravenous fluids initially. After a 4-day admission, patient is now ready to be discharged home, with planned follow-up with his GP in 6–8 weeks with repeat chest X-ray to check for resolution of consolidative changes. | |
| Component | Practical example |
| Demographic information | Joseph Tan 75-year-old Chinese gentleman Identification number XXXX Home address: 55 Lavender Street, Postal Code: 12345A |
| Important alerts | Drug allergies: co-trimoxazole (allergic reaction: rash) Adverse drug reactions: NSAIDs intolerance Contact precautions (Methicillin-Resistant Staphylococcus Aureus carrier) |
| Social set-up and premorbid function | Relevant social history Former smoker of 60 pack-years, non-alcohol drinker Retired cab driver Stays with wife and helper Has 2 children (1 son and 1 daughter) who stay apart but visits regularly Premorbid functional status ADL-independent, home ambulant with furniture cruising, and community ambulant with walking stick |
| Comprehensive past medical/surgical history and medication records | Medical history 1. Diabetes mellitus—latest HbA1c 6.5%, on oral hypoglycemic agents (metformin and glipizide) 2. Hypertension 3. Ischemic heart disease—had previous NSTEMI 10 years ago, with coronary angiogram showing single vessel disease (mid-left anterior descending artery (LAD) 80% stenosis), s/p percutaneous coronary intervention to culprit mid-LAD lesion; latest transthoracic echocardiogram 2 years ago shows preserved left ventricular ejection function 55% 4. Gold E COPD—on triple inhaler (Trelegy), may require long-term oxygen therapy in the near future Surgical history 1. Previous cholecystitis 10 years ago s/p laparoscopic cholecystectomy |
| History of presenting complaint and physical examination findings | Patient was admitted on D/MM/YYYY as a referral to the ED from his GP for breathlessness, productive cough, fever, and low oxygen saturations. Clinical history 1. Dyspnea of 3-day duration - Worse on exertion but also present at rest - Not worse on lying flat (orthopnea), no breathlessness that wakes him up from sleep (paroxysmal nocturnal dyspnea) - Intermittent in nature, feels getting slightly worse - Associated with productive cough of greenish phlegm - No sore throat or rhinorrhea - Not sure about presence of wheezing—did not notice noisy breathing - No chest pain - Has tactile fever, but did not measure temperature at home - No chills/rigors - No night sweats - No sick contacts 2. Giddiness of 1-day duration - Started feeling giddy since this morning - Non-vertiginous in nature - Worse on getting up from a lying/seated position (postural) - No headaches/nausea/vomiting - No other neurological symptoms such as numbness/weakness, speech or swallowing impairment, visual disturbances - No otological symptoms - Has not been eating or drinking much for past few days but no weight loss No other systemic complaints such as abdominal pain, urinary symptoms, or nausea/vomiting/diarrhea. Physical examination Vital signs on arrival in ED: T38.3, blood pressure 110/75 mmHg, heart rate 108/min, respiratory rate 28/min, oxygen saturations 87% on room air Postural blood pressure measurement—significant drop from 110/75 to 85/55 mmHg Alert and oriented, but lethargic looking Clinically dehydrated No cervical lymphadenopathy Heart sounds dual with no audible murmurs Lungs—presence of right lower zone crepitations, with bilateral end-expiratory rhonchi Abdomen soft and non-tender Neurological examination is unremarkable |
| Assessment and clinical course (include problem lists, differential considerations, relevant investigations, management, and disease progress/clinical response) | Clinical problem list 1. Community acquired pneumonia, complicated by infective exacerbation of COPD - Presented with 3-day history of breathlessness, productive cough (of greenish phlegm) and fever (Tmax 38.3 on arrival), with low oxygen saturations (87% on room air on arrival); clinical examination reveals right lower zone crepitations, bilateral end-expiratory rhonchi - Background of GOLD E COPD on triple inhaler therapy (on average 3 hospitalizations for exacerbations every year) - White cell count on arrival – 13 × 109/L (with neutrophilia) - Chest X ray on arrival shows right-lower zone consolidation - Patient was given antibiotics (Augmentin for 7 days, Azithromycin for 3 days) for community acquired pneumonia, nebulized bronchodilator therapy until wheezing/symptoms improved and steroids (prednisolone for 5 days) for flare of COPD. Patient’s inhaler technique was also assessed by respiratory subspecialty nurse and deemed to be good. Patient made a good clinical recovery, with symptomatic improvement, resolution of fever, and could wean off supplemental oxygen (2 L nasal prongs) by third day of admission. Complicated by a) KDIGO 1 AKI due to intravascular depletion (prerenal cause) - Baseline Creatinine levels 60–80 mmol/L > 110 mmol/L on arrival > > peaked 132 mmol/L > > 82 mmol/L on discharge - Given intravenous fluids in view of hypovolemic state with down-trending creatinine and eventual resolution of AKI on discharge b) Symptomatic postural hypotension - Presented with 1-day history of postural giddiness - Significant postural blood pressure drop noted in the first 2 days of admission - Subsequently, resolved with intravenous fluids c) Functional decline - Premorbidly ADL-independent, home-ambulant with furniture cruise, community-ambulant with walking stick - Noted during initial physiotherapy assessment that patient had reduced effort tolerance, and was slightly unsteady, requiring hand-hold assistance in short-distance ambulation - Subsequently, patient made significant improvements over next 3 physiotherapy sessions, and was near premorbid function by discharge 2. Hypoglycemic episode due to poor oral intake, background of diabetes mellitus on oral hypoglycemic agents - Resolved with oral dextrose-containing drink - Reduced glipizide dose from 5 to 2.5 mg BD |
| Record of medication changes | To complete 3 more days of oral Augmentin 625 mg BD, and 1 more day of oral prednisolone 30 mg OM on discharge. Changes to chronic medications: oral glipizide dose reduced from 5 mg BD to 2.5 mg BD in view of hypoglycemia episode. |
| Goals of care documentation | Discussed with patient and family this admission—decided for maximum non-invasive ventilation treatment, but not for intubation/mechanical ventilation, chest compressions, or intensive care unit transfer in the event of cardiac/respiratory arrest. |
| Expected follow-up plans and post-discharge instructions | To follow-up with patient’s GP in 6-8 weeks’ time for 1) continued follow-up of chronic conditions and titration of medications, 2) repeat chest X-ray for resolution of consolidative changes and for continued follow-up of chronic conditions. Patient is advised to be compliant to inhaler use, and keep well-hydrated/get up from seated/lying position slowly in view of postural hypotension. |
| Discharge information | Patient was discharged well and stable on DD/MM/YYYY from Department of General Medicine, XXX hospital back to his home. His condition was significantly improved at point of discharge. Consultant-in-charge: Dr. ABC Discharge summary completed by: Dr. DEF, MP12345A, House Officer. Discharge summary counter-signed by: Dr. GHI, M56789B, Registrar. Hospital contact information: 12345678. |
| Clinical vignette: Mr Joseph Tan is a 75-year-old Chinese male, with background of diabetes mellitus, hypertension, ischemic heart disease, GOLD E COPD, was recently admitted for community-acquired pneumonia complicated by infective exacerbation of COPD. He was treated with antibiotics for pneumonia and nebulized short-acting bronchodilators and short-course steroids for COPD exacerbation. His inhaler technique was also reviewed by the respiratory subspecialty nurse. During admission, he was also noted to have functional decline requiring physiotherapist review, and recurrent postural giddiness due to postural hypotension from dehydrated state requiring intravenous fluids initially. After a 4-day admission, patient is now ready to be discharged home, with planned follow-up with his GP in 6–8 weeks with repeat chest X-ray to check for resolution of consolidative changes. | |
| Component | Practical example |
| Demographic information | Joseph Tan 75-year-old Chinese gentleman Identification number XXXX Home address: 55 Lavender Street, Postal Code: 12345A |
| Important alerts | Drug allergies: co-trimoxazole (allergic reaction: rash) Adverse drug reactions: NSAIDs intolerance Contact precautions (Methicillin-Resistant Staphylococcus Aureus carrier) |
| Social set-up and premorbid function | Relevant social history Former smoker of 60 pack-years, non-alcohol drinker Retired cab driver Stays with wife and helper Has 2 children (1 son and 1 daughter) who stay apart but visits regularly Premorbid functional status ADL-independent, home ambulant with furniture cruising, and community ambulant with walking stick |
| Comprehensive past medical/surgical history and medication records | Medical history 1. Diabetes mellitus—latest HbA1c 6.5%, on oral hypoglycemic agents (metformin and glipizide) 2. Hypertension 3. Ischemic heart disease—had previous NSTEMI 10 years ago, with coronary angiogram showing single vessel disease (mid-left anterior descending artery (LAD) 80% stenosis), s/p percutaneous coronary intervention to culprit mid-LAD lesion; latest transthoracic echocardiogram 2 years ago shows preserved left ventricular ejection function 55% 4. Gold E COPD—on triple inhaler (Trelegy), may require long-term oxygen therapy in the near future Surgical history 1. Previous cholecystitis 10 years ago s/p laparoscopic cholecystectomy |
| History of presenting complaint and physical examination findings | Patient was admitted on D/MM/YYYY as a referral to the ED from his GP for breathlessness, productive cough, fever, and low oxygen saturations. Clinical history 1. Dyspnea of 3-day duration - Worse on exertion but also present at rest - Not worse on lying flat (orthopnea), no breathlessness that wakes him up from sleep (paroxysmal nocturnal dyspnea) - Intermittent in nature, feels getting slightly worse - Associated with productive cough of greenish phlegm - No sore throat or rhinorrhea - Not sure about presence of wheezing—did not notice noisy breathing - No chest pain - Has tactile fever, but did not measure temperature at home - No chills/rigors - No night sweats - No sick contacts 2. Giddiness of 1-day duration - Started feeling giddy since this morning - Non-vertiginous in nature - Worse on getting up from a lying/seated position (postural) - No headaches/nausea/vomiting - No other neurological symptoms such as numbness/weakness, speech or swallowing impairment, visual disturbances - No otological symptoms - Has not been eating or drinking much for past few days but no weight loss No other systemic complaints such as abdominal pain, urinary symptoms, or nausea/vomiting/diarrhea. Physical examination Vital signs on arrival in ED: T38.3, blood pressure 110/75 mmHg, heart rate 108/min, respiratory rate 28/min, oxygen saturations 87% on room air Postural blood pressure measurement—significant drop from 110/75 to 85/55 mmHg Alert and oriented, but lethargic looking Clinically dehydrated No cervical lymphadenopathy Heart sounds dual with no audible murmurs Lungs—presence of right lower zone crepitations, with bilateral end-expiratory rhonchi Abdomen soft and non-tender Neurological examination is unremarkable |
| Assessment and clinical course (include problem lists, differential considerations, relevant investigations, management, and disease progress/clinical response) | Clinical problem list 1. Community acquired pneumonia, complicated by infective exacerbation of COPD - Presented with 3-day history of breathlessness, productive cough (of greenish phlegm) and fever (Tmax 38.3 on arrival), with low oxygen saturations (87% on room air on arrival); clinical examination reveals right lower zone crepitations, bilateral end-expiratory rhonchi - Background of GOLD E COPD on triple inhaler therapy (on average 3 hospitalizations for exacerbations every year) - White cell count on arrival – 13 × 109/L (with neutrophilia) - Chest X ray on arrival shows right-lower zone consolidation - Patient was given antibiotics (Augmentin for 7 days, Azithromycin for 3 days) for community acquired pneumonia, nebulized bronchodilator therapy until wheezing/symptoms improved and steroids (prednisolone for 5 days) for flare of COPD. Patient’s inhaler technique was also assessed by respiratory subspecialty nurse and deemed to be good. Patient made a good clinical recovery, with symptomatic improvement, resolution of fever, and could wean off supplemental oxygen (2 L nasal prongs) by third day of admission. Complicated by a) KDIGO 1 AKI due to intravascular depletion (prerenal cause) - Baseline Creatinine levels 60–80 mmol/L > 110 mmol/L on arrival > > peaked 132 mmol/L > > 82 mmol/L on discharge - Given intravenous fluids in view of hypovolemic state with down-trending creatinine and eventual resolution of AKI on discharge b) Symptomatic postural hypotension - Presented with 1-day history of postural giddiness - Significant postural blood pressure drop noted in the first 2 days of admission - Subsequently, resolved with intravenous fluids c) Functional decline - Premorbidly ADL-independent, home-ambulant with furniture cruise, community-ambulant with walking stick - Noted during initial physiotherapy assessment that patient had reduced effort tolerance, and was slightly unsteady, requiring hand-hold assistance in short-distance ambulation - Subsequently, patient made significant improvements over next 3 physiotherapy sessions, and was near premorbid function by discharge 2. Hypoglycemic episode due to poor oral intake, background of diabetes mellitus on oral hypoglycemic agents - Resolved with oral dextrose-containing drink - Reduced glipizide dose from 5 to 2.5 mg BD |
| Record of medication changes | To complete 3 more days of oral Augmentin 625 mg BD, and 1 more day of oral prednisolone 30 mg OM on discharge. Changes to chronic medications: oral glipizide dose reduced from 5 mg BD to 2.5 mg BD in view of hypoglycemia episode. |
| Goals of care documentation | Discussed with patient and family this admission—decided for maximum non-invasive ventilation treatment, but not for intubation/mechanical ventilation, chest compressions, or intensive care unit transfer in the event of cardiac/respiratory arrest. |
| Expected follow-up plans and post-discharge instructions | To follow-up with patient’s GP in 6-8 weeks’ time for 1) continued follow-up of chronic conditions and titration of medications, 2) repeat chest X-ray for resolution of consolidative changes and for continued follow-up of chronic conditions. Patient is advised to be compliant to inhaler use, and keep well-hydrated/get up from seated/lying position slowly in view of postural hypotension. |
| Discharge information | Patient was discharged well and stable on DD/MM/YYYY from Department of General Medicine, XXX hospital back to his home. His condition was significantly improved at point of discharge. Consultant-in-charge: Dr. ABC Discharge summary completed by: Dr. DEF, MP12345A, House Officer. Discharge summary counter-signed by: Dr. GHI, M56789B, Registrar. Hospital contact information: 12345678. |
Demographic information
The discharge summary should begin with basic patient demographic information, including name, patient identification number, age, gender, and address, to explain to the reader who the discharge document is for and for verification purposes when patients or their caregivers/representatives collect it at/post-discharge.
Important alerts
Then, important alerts must be highlighted next, including patients’ drug allergies/adverse drug events, and specific clinical precautions to be privy to for subsequent clinical encounters (e.g. infection transmission-based precautions, presence of medical/surgical devices such as pacemakers or tracheostomy).
Social set-up and premorbid function
It is useful to document relevant pre-admission social circumstances (e.g. caregiving situation/stress, smoking status, alcohol use, recreational drug use, occupation, forensic history) and premorbid functional status in terms of basic/instrumental activities of daily living (ADL), mobility/ambulatory status and cognition (with previous cognitive assessment test results), which may relate to subsequent discharge planning issues, rehabilitation requirements and/or medical social interventions during hospitalization.
Comprehensive past medical/surgical history and medication records
The patients’ medical records must be tidied and kept up-to-date through a comprehensive review of previous discharge summaries, outpatient clinic consultation notes and patient-reported clinical events that have occurred since the previous admission. It is neater to group the patient’s past clinical issues into medical and surgical histories and further list them in a systematic manner (e.g. in terms of relevance, importance or frequency). For specific medical conditions, adding a few lines of relevant information pertaining to their status/disease control, presence of associated complications and active treatment/follow-up plans may be warranted. Moreover, for patients who are admitted to specific subspecialties, separating a section to provide a more detailed medical history that is subspecialty specific may sometimes be prudent.
In addition, it would be helpful to clearly list the pre-admission medications after inpatient medication reconciliation, by including the dose/frequency/route of prescribed medications, as well as usage of over-the counter medications, supplements and/or traditional/alternative medicines.
History of presenting complaint and physical examination findings
In this section, the reason for patient admission (i.e. history of presenting complaint) should be clearly documented, together with the admission date and source of referral to the hospital (e.g. referred from a general practitioner (GP) to the emergency department (ED), direct admission from an outpatient clinic, or interhospital transfer). The salient aspects of the patient’s initial history and physical examination findings gathered by the ED and inpatient team should be summarized. Depending on local practice, this section may be written in either a concise bullet-point form or a summarized prose format. The clinical history should be documented in the following manner: main presenting complaint, characterization of the symptom (e.g. nature/character, onset, duration, progression, alleviating/exacerbating factors), other associated symptoms and significant negatives (especially to rule out red-flag symptoms), systems review, and only the salient/relevant aspects of past medical/surgical history, drug history, social history and family history (e.g. risk factors that may affect the pretest probability of disease and the ranking of differential diagnoses). The physical examination findings should be summarized as follows: clinical parameters/vital signs (to describe the patient’s clinical/hemodynamic stability) and targeted examinations (to evaluate for possible differential diagnoses, underlying etiologies and associated complications).
Assessment and clinical course (including problem lists, differential considerations, relevant investigations, management, and disease progress/clinical response)
In this section, the clinical impression of patient’s presenting complaint(s) and given diagnoses must be documented, with clear clinical problem statements and descriptors. Specifically, the heading for each identified clinical problem/issue should be a provisional or definitive diagnosis and not merely a descriptor of clinical symptoms/signs (e.g. asthma exacerbation as opposed to breathlessness and wheezing). Where applicable, identified causes or precipitants of current presentation should be included (e.g. acute decompensated heart failure due to fluid indiscretion and medication non-compliance) and severity of illness described (e.g. KDIGO 3 [67] acute kidney injury (AKI), severe community-acquired pneumonia (ATS 1 major criterion [68])). Then, problem representation statements, defined as “one-sentence summaries defining the specific case in abstract terms” [69], can be used to demonstrate clinical reasoning and explain how the medical team arrived at this provisional/established diagnosis. For example, a patient diagnosed with acute gout flare can have a problem statement that reads “presented with sudden-onset, inflammatory, monoarticular right knee pain that woke patient up from sleep, associated with joint swelling, tenderness, with no features suggestive of chronic joint disease/deformity, on a background of two prior similar episodes in the past 2 years” [69]. In addition, clinical considerations and rationale for excluding relevant differential diagnoses may also be included if appropriate.
Next, relevant investigations pertaining to individual clinical problems/diagnoses can be summarized neatly into categories such as blood/laboratory investigations, imaging modalities, microbiological investigations, and/or diagnostic procedures. Clinical management can be described in terms of conservative (e.g. watch-and-wait) or lifestyle modification measures, pharmacological therapies and/or surgical/procedural interventions. Any subspecialty consultations should also be documented, including their expert opinions on the clinical problem and medical recommendations.
Subsequently, the patient’s clinical trajectory and response to treatment must be clearly written, with the rationale for changes in treatment explained (e.g. broadening of antimicrobial cover due to possibility of nosocomial infections or lack of clinical response, or narrowing antimicrobial choice to culture sensitivities). Of note, shared clinical decision-making (with patients/families) to hold off further evaluations or treatments for certain conditions, for instance, due to conservative goals of care, specific patient preferences, or low likelihood of intervention changing clinical/treatment trajectory, should be documented clearly [67, 68].
Of note, any disease- or treatment-related complications should be highlighted in a sub-section under the relevant clinical issue/problem, and not constitute separate “diagnoses”.
Other non-medical issues, such as psychosocial, functional, nutritional/swallowing and cognitive issues should also be documented separately for holistic purposes, together with the assessments, recommendations, and plans provided by the relevant allied health professionals.
Record of medication changes
For both patients/caregivers and primary care providers, all medication changes (e.g. newly initiated medications, dose adjustments (old and new doses), or discontinuation of chronic medications) must be clearly documented, together with the rationale. For drugs that need to be restarted eventually (e.g. resuming sodium-glucose transport protein-2 (SGLT-2) inhibitors after an infective episode), the relevant post-discharge instructions or follow-up plan must be provided.
Goals-of-care documentation
In the context of a rapidly aging population with greater burden of comorbid conditions, coupled with the need to provide person-centered, autonomous clinical decision-making, goals-of-care discussions have become increasingly important and relevant to patient care [70]. These could take the form of advance care planning, serious illness conversations or advance medical directives that are usually performed in outpatient settings or code/resuscitation status discussions in hospital settings [12]. To ensure that patients’ wishes/preferences are adhered to and prevent non-beneficial invasive/life-sustaining interventions from being carried out inappropriately, goals-of-care decision-making must be documented clearly for reference by future care providers. For example, a frail and elderly, but cognitively intact patient with advanced chronic obstructive pulmonary disease (COPD) may be suitable for a maximum trial of non-invasive ventilation for future exacerbations with decompensated hypercapnic respiratory failure but is not for intubation for mechanical ventilation.
Expected follow-up plans and post-discharge instructions
To ensure continuity of care and seamless transition from hospital to primary care/outpatient services, follow-up plans and appointments must be clearly documented. Outstanding investigations that need to be traced in the outpatient setting should be documented clearly with memos written to the relevant care providers, who need to review and act on the investigation findings. For patient’s primary or outpatient specialist ambulatory care providers, post-discharge memos are helpful to keep them updated of relevant clinical events that occurred during admission, medication changes, and specific aspects of patient care that they should monitor or review post-discharge at their follow-up. Any new appointments and technical visits (e.g. for laboratory tests or scans) scheduled for the patients should also be documented clearly for their (or their caregivers’) reference.
Discharge information
At the end of the discharge summary, the following discharge-related information must be documented: date of discharge, specialty at discharge, consultation-in-charge, discharge condition, discharge disposition (e.g. home, step-down/interim care services), and type of discharge (e.g. normal discharge, discharge against medical advice, medical abscondment). In addition, relevant post-discharge instructions, specific return- or care-related advice, and hospital contact information should also be written for patients/caregivers’ perusal. Finally, relevant information of the medical provider who completed the discharge summary, such as name, medical registration number, clinical grade/rank, should be presented as part of proper clinical documentation and transparency. It is good clinical practice for discharge summaries written by junior staff to be co-signed/reviewed by senior members of the medical team, who can help to ensure the accuracy and completeness of the information provided, and provide necessary feedback on its quality to the junior physicians.
Pedagogical strategies for training and assessment of discharge summary writing
To develop skills in writing a concise, relevant and high-quality discharge summary, an iterative process of learning, practice, assessment and feedback is needed. To optimize this process, a few pedagogical strategies can be adopted.
First, didactic teaching is required to impart relevant knowledge on the importance and core components of a discharge summary [1]. Such foundational teaching can be conducted in mass lectures or small-group tutorial formats and can be performed either in person or through virtual platforms (e.g. e-learning modules). Following didactic teaching, hands-on training can be conducted via preset case scenarios of varying types and levels of difficulty, with facilitator guidance to navigate the process of crafting a suitable discharge summary and formulating nuanced, well-reasoned problem lists [1].
Second, regular clinical audits and in-training assessments of discharge summary standards can be performed via standardized rubrics/assessment criteria. For official clinical audits, the plan–do–study–act (PDSA) model for quality improvement can be adopted, where a discharge summary checklist is first developed; then, an audit of recent hospital discharge summaries is conducted, with weak points flagged, leading to targeted interventions for clinicians with repeat audits postintervention [12]. Regular assessments of junior physicians or medical residents can be performed via discharge summary checklists adapted from the Professional Records Standard Body [71], Royal College of Physicians [72], or in-house audit tools. Subsequently, constructive feedback on actual completed discharge summaries can be provided by assigning clinical supervisors to physicians-in-training at regular intervals based on these predefined metrics. To improve feedback literacy/receptivity, methods such as analysing exemplars and near-peer feedback can also be adopted [73].
Finally, to standardize the quality of discharge summaries, institutional templates can be developed and made available in electronic medical records (EMRs) [1, 32]. Moreover, EMR prompts can also be used to remind providers of salient aspects of discharge summary writing (e.g. indicating rationale for medication changes) [32] or avoid bad habits such as excessive/inappropriate abbreviations [31]. In addition, artificial intelligence (AI) software (e.g. ChatGPT-4) has also been found to be valuable in writing high-quality discharge summaries containing the necessary information with the appropriate input and pre-training [13–15]. Nonetheless, AI platforms have pitfalls—for example, the quality of their output depends on fed data (i.e. the “garbage-in, garbage-out” principle) [74]), lack transparency in their processes (i.e. the “black-box” problem) [74, 75], lack accountability for errors [76], and privacy concerns [75].
Conclusion
In summary, a discharge summary is an essential clinical document written to facilitate smooth transition of care from hospital-to-community, patient adherence to treatment/follow-up, and overall patient safety/outcomes. We have reviewed the essential components of a high-quality discharge summary, developed a mnemonic-based “DISCHARGED” model for junior physicians to adopt in clinical practice and shared pedagogical strategies for the training and assessment of discharge summary writing.
Author Contributions
IKSN wrote the initial manuscript draft. DT, TS, KSY, KLEC, CEC, DBT critically reviewed and edited the manuscript. All authors conceived the study idea and contributed to the creation of the mnemonic-based “DISCHARGED” model.
Conflict of interest statement
The authors have no conflicts of interest to declare.
Funding
None required.
