Discharge Summary Template for Inpatient Hospital Stay

Date of Admission

[Enter the date of admission based solely on information from notepad, past records, and dictation.]

Date of Discharge

[Enter the date of discharge based solely on information from notepad, past records, and dictation.]

Diagnosis Most Responsible for Hospital Stay

[List the primary diagnoses responsible for the hospital stay in numbered format, using only information from notepad, past records, and dictation.] For example: 1. [Primary Diagnosis 1] 2. [Primary Diagnosis 2]

Diagnosis not affecting Length of Stay/Past Medical History

[List diagnoses that did not affect length of stay or represent past medical history in numbered format, using only information from notepad, past records, and dictation.] For example: 1. [Past Medical Condition 1] 2. [Past Medical Condition 2]

ID and Clinical Course in Hospital

[Include patient demographics (e.g., age, gender) and a detailed narrative of the clinical course during the hospital stay, based solely on information from notepad, past records, and dictation.]

Operative Reports

[Include operative or procedural reports if relevant and documented in notepad, past records, or dictation. If no surgeries or procedures were performed or discussed, omit this section.]

Relevant Consultants

[List any specialists or consultants involved during the hospital stay, based only on information from notepad, past records, and dictation. If none, omit this section.]

Medications on Discharge

[List all medications prescribed at discharge, using only information from notepad, past records, and dictation.]

Code Status

[Document the patient's code status as recorded in notepad, past records, and dictation. If none, omit this section.]

Follow up and Plan

[Provide detailed follow-up instructions and plans for the patient after discharge, including where the patient will be discharged to, what the plans are following discharge, any follow up for the patient and treatment. Use information information solely from notepad, past records, and dictation. Use paragraph and full sentences.]