Discharge Summary

Discharge

1

Demographics

  • Patient name, NHS/MRN, DOB
  • Admission and discharge dates
  • Ward / consultant
2

Diagnoses

  • Primary diagnosis
  • Secondary diagnoses / comorbidities
3

Procedures

  • Operations, endoscopies, interventions with dates
4

Clinical Summary

  • Why admitted
  • Key investigations + results
  • Treatment received and response
5

Medications on Discharge

  • New medications + indication + duration
  • Changes to existing
  • Stopped medications
6

Follow-up

  • Outpatient clinic + timing
  • Investigations pending
  • Community team referrals
7

Information Given

  • To patient and family
  • Safety-netting advice
8

GP Actions

  • Specific tasks for primary care
  • Blood tests required + timing

Tip: Copy to paste into EMR, or Print to save as PDF.

WardRound

WardRound

Clinical Decisions in Seconds