A discharge report is a foundational communication tool provided to a patient upon transition from a medical facility, such as a hospital or rehabilitation center, back to their home or another care setting. This formal document bridges the gap between the structured care received during the stay and the self-management or community care that follows. Its primary purpose is to ensure the safe progression of a patient’s recovery and treatment plan. The report details the care received and provides actionable instructions for the patient and their next healthcare providers.
Summary of Hospitalization and Diagnosis
This section provides a detailed record of the administrative and clinical events during the patient’s stay. It begins with demographic information, the attending physician’s name, and the dates of admission and discharge. These details ensure accurate patient identification and provide a clear timeline for the episode of care.
The report formally states the primary reason for hospitalization, along with any secondary diagnoses or pre-existing conditions that influenced treatment. It includes a narrative summary of the hospital course, outlining major procedures, diagnostic tests, and significant findings. This overview provides the context of the patient’s illness and the rationale behind the treatments administered for subsequent care providers. The patient’s condition at the time of discharge is also noted, giving a baseline assessment of their immediate health status.
Post-Discharge Medication Instructions
This section is one of the most detailed and risk-sensitive components of the discharge report. It provides a complete and reconciled list of all medications the patient should be taking after leaving the facility. Medication reconciliation compares the patient’s home medications with the drugs prescribed during the hospital stay and the final discharge orders.
Each listed medication must clearly specify the drug name, exact dosage (e.g., milligrams), route of administration, and frequency of use (e.g., twice daily). The report differentiates between new prescriptions, medications with changed dosage or frequency, and home medications that were temporarily stopped. Clear instructions regarding the purpose of each drug help promote patient adherence. This detail is necessary to mitigate the risk of medication errors, which are common during transitions of care.
Required Follow-Up Care and Appointments
The discharge report outlines the necessary medical care the patient must receive to complete their recovery. This includes specific instructions for scheduling follow-up appointments with external healthcare providers. These appointments typically involve a visit with the primary care physician or a specialist who managed the patient’s condition.
Specific referrals for therapeutic services are also documented, such as physical therapy, occupational therapy, or specialized wound care. Beyond appointments, the report provides non-medication instructions related to recovery, which may include dietary restrictions or recommendations. These instructions might involve a low-sodium diet, specific calorie intake goals, or limitations on physical activity, such as avoiding lifting heavy objects.
Warning Signs and Emergency Contact Information
The final section focuses on patient safety by detailing specific symptoms, or “red flags,” that require immediate medical attention. These instructions are designed to prevent potential complications from escalating into a serious medical event or hospital readmission. Examples of these symptoms might include a sudden, high fever, unexpected bleeding, or a rapid increase in pain not managed by prescribed medication.
The report provides clear guidance on when the patient should seek urgent care, differentiating between symptoms that can wait for a scheduled follow-up and those requiring an emergency department visit. Direct contact information is included for the patient’s care team, such as a nurse line or the facility’s emergency contact number. This ensures the patient has an immediate resource to consult if they experience any warning signs after discharge.