Hospital Discharge Summary

What Is a Hospital Discharge Summary Template?

A hospital discharge summary template is a predefined format used by medical professionals to compile and present a patient's data at the point of discharge. Using a standardized template ensures consistency and helps in relaying accurate, concise details about the patient's health state during admission, their diagnosis, treatment received in the hospital, and follow-up care plan. 

Using sample hospital discharge summary

Examining a sample hospital discharge summary can be beneficial for medical professionals to understand the structure and content it should contain. It could also help patients and their caregivers comprehend what details to expect in the form. The summary typically begins with the patient's personal details, followed by an admission diagnosis, detailed treatment information, and the discharge plan.

How to Fill Out the Discharge Summary From Hospital

It is imperative to understand the hospital discharge summary requirements for the successful completion of the form. Follow these steps to get a properly completed template:

1. Fill in the date at the top of the page.
2. Affix the patient information label in the space provided.
3. Finalize the "Hospital Discharge Summary" part of this form. Start with checking the appropriate box for "Allergies & Adverse Reaction" and filling in any relevant information.
4. Listing the name of each medication, its strength, and the times of day it should be taken.
5. Indicating the purpose of each medication and any special instructions.
6. Obtaining the medical officer's signature and printing their name and title.
7. Complete the "Hospital Discharge Summary - Medications" section by checking the appropriate box for whether the patient has consented to community pharmacy contact.
8. Indicating whether the patient had a Webster pack on admission or if one is requested for discharge.
9. Providing the contact details for the community pharmacy.
10. Make a copy of the completed form to be faxed to the patient's referring community practitioner (GP or other).
11. Place the original form in the patient's clinical record.

Also, please remember that the discharge summary hospital document has a binding margin, so it is important not to write in that area.

Required information on this form

To fill out the discharge summary from hospital format document, the following information is required:

• Information about the patient, including name and health record number.
• Allergies and adverse reactions to medications.
• List of medications, including name, strength, times of day to be taken, purpose, and any special instructions.
• Community pharmacy contact details, including whether the patient has consented to contact and whether a Webster pack is requested.
• Psychosocial information, including nursing care, living skills, rehabilitation, and counseling.
• Accommodation on discharge, including contact phone number.
• Follow-up appointments confirmed with healthcare professionals.
• Summary of care given, including assessments on admission and discharge.
• Health of the Nation Outcome Scales (HoNOS) total score on admission and discharge.
• Edinburgh PND scale score on admission and discharge.
• Patient or caregiver signature.