A discharge note, also known as a discharge summary, is a formal document that synthesizes a patient’s entire hospital stay. This narrative ensures a smooth transition back to community providers or subsequent care facilities. The document acts as a communication tool, informing primary care doctors and other specialists about the patient’s inpatient management and ongoing needs. Studies show that timely and structured summaries help reduce the risk of readmissions and patient complications following hospitalization. The summary also serves as a comprehensive legal record of the patient’s treatment, diagnostic findings, and condition upon release.
Summarizing the Hospital Course
The hospital course section must document the patient’s clinical trajectory through the discharge date. This narrative begins with a brief summary of the History of Present Illness (HPI) and the admission diagnosis, clearly stating why the patient required inpatient care. The goal is to establish the context for the entire hospitalization without reproducing the admission note.
Following the initial context, the summary should progress chronologically, focusing only on the events that meaningfully influenced the patient’s stay or dictated the ongoing treatment plan. This includes a description of significant diagnostic findings, such as imaging results or laboratory values that shaped clinical decision-making. Procedures and treatments performed, including any surgical interventions or therapeutic changes, must be documented.
The narrative should clearly track the patient’s response to the medical interventions, noting whether their clinical status improved or deteriorated over time. Any complications or adverse events encountered during the stay, along with how those issues were managed, must be included. For instance, if a new medication was started, the summary should briefly explain the rationale for its initiation and the patient’s reaction to it.
Conciseness is paramount; the summary must focus on medically relevant details that inform the next provider about the patient’s journey and the reasoning behind the discharge plan.
Documenting Status and Disposition
This section shifts focus to the patient’s condition at release, known as the discharge status. This documentation must include a clear list of all active discharge diagnoses, with the primary reason for hospitalization listed first. These diagnoses are often linked to the appropriate International Classification of Diseases (ICD) codes, which are used for accurate billing and record-keeping.
The patient’s physical and mental state must be described using objective terms like “stable,” “improved,” or “ambulatory,” along with any remaining deficits or needs. This provides the receiving facility or provider with an immediate understanding of the patient’s current functional capacity.
Documenting the specific disposition identifies the patient’s destination after leaving care. Standardized, two-digit alphanumeric Discharge Status Codes are used to indicate whether the patient is going home (e.g., Code 01), to a Skilled Nursing Facility (SNF), or to an Inpatient Rehabilitation Facility (IRF). Using the correct disposition code is important for billing and for the receiving facility’s ability to submit claims.
To finalize the legal record, the note must be signed by the attending physician responsible for the patient’s care. The exact date and time of the patient’s discharge must also be included.
Discharge Instructions
The discharge instructions represent the forward-looking plan for patient safety and outcome. These instructions must be written in clear, accessible language, avoiding medical jargon to ensure patient comprehension. One of the first elements is a complete medication reconciliation of all medications the patient was taking before, during, and after the hospitalization.
This reconciliation must explicitly list every medication to be continued, discontinued, or newly prescribed, including clear dosing schedules and the purpose of each drug. Medication discrepancies are a common source of adverse events after discharge, emphasizing the need for accuracy in this section.
The follow-up plan must be specific, moving beyond generic advice like “follow up as needed.” This section needs to provide definite appointments with specific providers, including the name of the primary care physician or specialist and the timeframe for the visit, such as “within 7 days” or “within 2 weeks.” Pre-scheduling these appointments before the patient leaves the hospital significantly increases the likelihood of attendance.
Clear guidelines regarding activity and diet restrictions are necessary for a safe recovery. This includes specific instructions on physical limitations, such as weight-bearing restrictions or limitations on lifting, and detailed wound care protocols if applicable. Nutritional advice, including any diet modifications necessary for managing a chronic condition like diabetes or heart failure, should be provided.
The instructions must detail the “warning signs” or “red flags” that should prompt the patient to seek immediate medical attention. This list should specify symptoms that necessitate a call to the provider versus symptoms that require an immediate return to the emergency department. Before the patient leaves, providers should use techniques like “teach-back” to confirm the patient and caregiver understand the instructions, the medication plan, and when to seek urgent care.