scientific-skills/clinical-reports/assets/discharge_summary_template.md
Patient Name: [Last, First]
Medical Record Number: [MRN]
Date of Birth: [MM/DD/YYYY]
Age: [years]
Sex: [M/F]
Admission Date: [MM/DD/YYYY]
Discharge Date: [MM/DD/YYYY]
Length of Stay: [X days]
Admitting Service: [Medicine/Surgery/Cardiology/etc.]
Attending Physician: [Name]
Primary Care Physician: [Name and contact]
Consulting Services: [List specialties that saw patient]
[Primary reason for hospitalization]
Example: "Acute decompensated heart failure"
[Numbered list, prioritized by clinical significance]
Primary Diagnosis:
Secondary Diagnoses: 2. [Secondary diagnosis with ICD-10 code] 3. [Additional diagnosis with ICD-10 code] 4. [Comorbidity with ICD-10 code]
Example:
1. Acute decompensated heart failure (I50.23)
2. Acute kidney injury on chronic kidney disease stage 3 (N17.9, N18.3)
3. Hypokalemia (E87.6)
4. Type 2 diabetes mellitus (E11.9)
5. Coronary artery disease (I25.10)
[Comprehensive yet concise narrative of hospital stay - can be organized chronologically or by problem]
[Date Range or Hospital Day 1-X]:
[Patient Name] was admitted to the [service] service with [chief complaint/presenting problem]. On presentation, patient was [clinical status]. Initial workup revealed [key findings].
[Description of key events, interventions, and response to treatment organized by day or by problem]
Hospital Day 1: [Events and interventions]
Hospital Day 2-3: [Progression, response to treatment]
Hospital Day 4-7: [Continued treatment, consultations, procedures]
Final Hospital Days: [Stabilization, preparation for discharge]
1. [Primary Problem]
2. [Secondary Problem]
3. [Additional Problems]
Consultations Obtained:
Procedures Performed:
Significant Diagnostic Studies:
Complications:
[Procedure name] ([Date])
[Additional procedures]
[One paragraph summary suitable for quick reference]
Example:
Mr. [Name] was admitted with acute decompensated heart failure in the setting of
medication non-adherence. He was diuresed with IV furosemide with net negative
5 liters over 3 days, with significant improvement in dyspnea and resolution of
lower extremity edema. Echocardiogram showed EF 30%, similar to prior. Kidney
function improved to baseline with diuresis. He was transitioned to oral diuretics
on hospital day 3 and remained stable. Patient was ambulating without dyspnea on
room air by discharge. Comprehensive heart failure education was provided.
Vital Signs:
General: [Appearance, distress level]
Cardiovascular: [Heart sounds, edema]
Pulmonary: [Breath sounds, work of breathing]
Abdomen: [Tenderness, bowel sounds, distention]
Extremities: [Edema, pulses]
Neurological: [Mental status, focal deficits]
Wounds/Incisions (if applicable): [Healing status]
| Test | Result | Reference Range |
|---|---|---|
| WBC | [Value] | [Range] |
| Hemoglobin | [Value] | [Range] |
| Platelets | [Value] | [Range] |
| Sodium | [Value] | [Range] |
| Potassium | [Value] | [Range] |
| Creatinine | [Value] | [Range] |
| [Other relevant labs] | [Value] | [Range] |
[Study name] ([Date]): [Key findings relevant to outpatient management]
[Complete list with clear indication of changes from admission]
[Consolidated list in simple format for patient]
1. Furosemide 40 mg by mouth once daily [NEW - for fluid management]
2. Carvedilol 12.5 mg by mouth twice daily [CONTINUED]
3. Lisinopril 20 mg by mouth once daily [CONTINUED]
4. Metformin 1000 mg by mouth twice daily [CONTINUED]
5. Aspirin 81 mg by mouth once daily [CONTINUED]
Overall Status: [Stable / Improved / Baseline / Requires continued care]
Specific Assessments:
Example:
Patient is hemodynamically stable, ambulatory without assistance, no supplemental
oxygen requirement, euvolemic on physical exam, pain well-controlled, and has
returned to baseline functional status.
[Where patient is going after hospital discharge]
Options:
Discharge Disposition: [Selection from above]
Services Arranged:
[Specialty/PCP] with Dr. [Name]
[Additional appointments]
Call your doctor or return to emergency department if you experience:
Example for heart failure:
- Worsening shortness of breath or difficulty breathing
- Chest pain or pressure
- Severe swelling in legs or abdomen
- Weight gain more than 2 lbs in one day or 5 lbs in one week
- Dizziness, lightheadedness, or fainting
- Fever >101°F
- Any other concerning symptoms
Emergency Contact Numbers:
Topics discussed with patient and/or family:
Patient/Family Understanding: [Patient and family verbalize understanding of discharge instructions / Teach-back method used and patient able to repeat key points / Interpreter used]
Written Materials Provided:
Code Status: [Full code / DNR / DNI / Other limitations]
[If changed during hospitalization, note when and why]
[Relevant social factors affecting discharge plan]
[Tests or consultations still pending that require outpatient follow-up]
Prepared by:
[Physician name, credentials]
[Pager/Contact number]
Cosigned by (if resident/fellow):
[Attending physician name]
Date and Time: [MM/DD/YYYY at HH:MM]
Electronically signed: [Yes/No]
Timing Requirements:
Distribution:
Quality Measures: