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What is a Discharge Summary?
A discharge summary is a comprehensive report of a patient's hospital stay, including admission and discharge dates, diagnosis, treatments, and outcomes. It is typically generated by the hospital's medical staff and is used to provide a concise summary of a patient's hospitalization. The discharge summary also serves as a form of communication between the hospital and other health care providers, such as the patient's primary care physician or a specialist.
Why is a Discharge Summary Important?
The discharge summary is an important document for the patient and their primary care provider. It provides a comprehensive overview of the patient's hospital stay and is a key source of information for the patient's aftercare. It is also used to document the care the patient received and ensure continuity of care.
How is a Discharge Summary Prepared?
The discharge summary is typically prepared by the medical staff shortly before the patient is discharged from the hospital. It includes information such as the patient's diagnosis, treatments, and outcomes. It also includes the patient's current medications, follow-up instructions, and any follow-up appointments that were scheduled.
What Should a Discharge Summary Include?
A discharge summary should include the following information: patient's name, date of birth, admission and discharge dates, diagnosis, treatments, medications, follow-up instructions, and any follow-up appointments that were scheduled. It should also include any notes from the attending physician, including any changes in the patient's condition and any recommendations for follow-up care.
Who Receives a Discharge Summary?
The discharge summary is typically sent to the patient's primary care provider, as well as any specialists that the patient may have seen during their hospital stay. It is also sent to any other providers, such as physical therapists or home health agencies, that are involved in the patient's aftercare.
Sample Discharge Summary
 Patient Name: John Smith 
 Date of Birth: 1/1/2000 
 Admission Date: 1/15/2023 
 Discharge Date: 1/30/2023 
 Diagnosis: Appendicitis 
 Treatment: Laparoscopic appendectomy 
 Medications: Acetaminophen, antibiotics 
 Follow-up Instructions: Follow-up appointment with primary care physician in two weeks 
 Follow-up Appointments: Physical therapy appointment in one week 
 Notes: Patient has recovered well and is ready for discharge.
 
 Patient Name: Jane Doe 
 Date of Birth: 6/6/1998 
 Admission Date: 2/1/2023 
 Discharge Date: 2/15/2023 
 Diagnosis: Pneumonia 
 Treatment: Antibiotics 
 Medications: Azithromycin, ibuprofen 
 Follow-up Instructions: Follow-up appointment with primary care physician in two weeks 
 Follow-up Appointments: None 
 Notes: Patient is recovering well and is ready for discharge.
 
 Patient Name: David Jones 
 Date of Birth: 11/11/1995 
 Admission Date: 3/1/2023 
 Discharge Date: 3/15/2023 
 Diagnosis: Urinary tract infection 
 Treatment: Antibiotics 
 Medications: Amoxicillin, ibuprofen 
 Follow-up Instructions: Follow-up appointment with primary care physician in two weeks 
 Follow-up Appointments: None 
 Notes: Patient is responding well to treatment and is ready for discharge.
 
Conclusion
A discharge summary is an important document that provides a comprehensive overview of a patient's hospital stay. It is typically generated by the hospital's medical staff and serves as a form of communication between the hospital and other health care providers. It includes information such as the patient's diagnosis, treatments, medications, follow-up instructions, and any follow-up appointments that were scheduled. It is typically sent to the patient's primary care provider, as well as any specialists that the patient may have seen during their hospital stay.