A discharge note, also known as a discharge summary, serves as the primary communication tool facilitating a patient’s safe movement from the hospital to the next level of care. This formal document synthesizes the entire hospital episode into a concise, actionable record for both the patient and subsequent healthcare providers. By clearly outlining the events of the stay and the plan for recovery, this document ensures a seamless transition and works to reduce the risk of adverse events and unplanned readmissions.
Summarizing the Hospital Stay
The first section of a comprehensive discharge note establishes the administrative and clinical context of the patient’s hospitalization. It begins with the fundamental data, including the admission and discharge dates, along with the names of the attending physician and any consulting specialists involved in the patient’s care. This information provides a clear timeline and identifies the professionals responsible for the inpatient treatment.
The note must clearly state the admitting diagnosis—the reason the patient was originally hospitalized—and the final diagnosis, often represented by standardized ICD codes. A brief, chronological summary of the hospital course is then included, explaining the “why” and “what was done” during the stay. This narrative must be concise, highlighting only those events that influenced the final diagnosis or the chosen treatment plan, such as significant diagnostic test results or major procedures performed. For instance, a summary might detail the progression of an infection, the response to a specific therapy, or the outcomes of a surgical intervention. The section concludes with a description of the patient’s condition and disposition status at the time of departure, such as whether they are stable, improved, or being transferred to a skilled nursing facility. This retrospective summary sets the stage for the forward-looking instructions that follow.
Ensuring Medication Safety
Medication management is one of the most complex and error-prone aspects of the hospital discharge process. The discharge note must contain a detailed section dedicated to medication reconciliation, which formally compares a patient’s prior medication list with the new orders at discharge. This involves reviewing medications taken before admission, those administered during the stay, and the final prescriptions they will take home.
The goal is to identify and resolve any discrepancies, such as omissions, duplications, or incorrect dosages, which can reduce medication errors by 50% to 94% when formalized processes are followed. The document must clearly classify every medication, including those continued from home, new medications started in the hospital, and pre-admission medications that were stopped, with a documented reason for discontinuation. Each entry must specify the drug name, dosage, frequency, and route of administration.
The note must reflect that specific patient education occurred regarding medication use. This includes documenting that the patient understands the purpose of each new drug, potential common side effects to monitor for, and clear instructions on what steps to take if a dose is accidentally missed. Furthermore, all known patient allergies must be prominently documented in this section to prevent potential adverse drug reactions in the outpatient setting.
Post-Discharge Care Plan
The final section is prospective, detailing instructions for the patient and the communicating physician regarding care outside the hospital. This plan ensures continuity of care and provides a structured path toward recovery. Specific follow-up instructions are mandatory, outlining who the patient needs to see (e.g., a primary care physician or specialist) and the expected timeframe for that appointment, often within seven to thirty days of discharge.
The note must also list any required diagnostic tests, such as blood work or imaging studies, that need to be scheduled post-discharge, including the timeframe for completion. Clear, actionable instructions on activity and dietary restrictions must be provided, such as weight-bearing limits following a procedure or specific recommendations for wound care. For patients with complex needs, this may include arranging for home health services or specialized medical equipment.
A particularly important aspect for patient safety is the inclusion of “red flags” or warning signs that require immediate medical attention. This means explicitly listing symptoms, such as a sudden high fever, increasing pain not controlled by prescribed medication, or unexpected bleeding or swelling, that should prompt the patient to contact their provider or return to the emergency department. Providing this information empowers the patient and their caregivers to recognize potential complications and seek timely intervention, which can significantly reduce the risk of hospital readmission.