hospitalist Template

Hospitalist Discharge Summary Template

Comprehensive discharge summary template for hospital medicine.

By Dr. Ephrem Nigussie, MD

TL;DR

  • When to use: All hospital discharges
  • What it includes: Hospital course, discharge meds, follow-up, pending results

Template

DISCHARGE SUMMARY

PATIENT INFORMATION:
Admission Date: [XX/XX/XXXX]
Discharge Date: [XX/XX/XXXX]
Length of Stay: [XX] days
Attending Physician: [XX]
Dictating Physician: [XX]

ADMITTING DIAGNOSIS:
1. [XX]

DISCHARGE DIAGNOSES:
1. [Primary diagnosis with specificity]
2. [Secondary diagnosis]
3. [Other relevant diagnoses addressed]

PRINCIPAL PROCEDURE(S):
1. [Procedure] - [Date] - [Performing physician]
2. [Procedure] - [Date] - [Performing physician]
Or: None performed this admission

CONSULTANTS:
- [Specialty]: [Consultant name] - [Reason for consult]
- [Specialty]: [Consultant name] - [Reason for consult]

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BRIEF HOSPITAL COURSE:

PRESENTING HISTORY:
[XX]-year-old [male/female] with history of [relevant PMH] who presented on [date] with [chief complaint/presenting symptoms]. [Brief ED/admission workup and initial findings].

HOSPITAL COURSE BY PROBLEM:

Problem #1: [Primary diagnosis]
[Concise narrative: What was found, what was done, how patient responded, final status at discharge]

Problem #2: [Secondary diagnosis]
[Concise narrative]

Problem #3: [Other relevant problem]
[Concise narrative]

DISCHARGE CONDITION:
- Mental Status: [Alert and oriented / other]
- Activity Status: [Ambulatory - independent / with assist / non-ambulatory]
- Diet: [Regular / specific restrictions]

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DISCHARGE MEDICATIONS:

CONTINUED MEDICATIONS (no changes):
1. [Medication] [dose] [route] [frequency]
2. [Medication] [dose] [route] [frequency]

NEW MEDICATIONS:
1. [Medication] [dose] [route] [frequency] - for [indication]
2. [Medication] [dose] [route] [frequency] - for [indication]

CHANGED MEDICATIONS:
1. [Medication] [old dose] -> [new dose] - [reason for change]
2. [Medication] changed from [old] to [new] - [reason]

STOPPED MEDICATIONS:
1. [Medication] - [reason for discontinuation]
2. [Medication] - [reason for discontinuation]

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FOLLOW-UP APPOINTMENTS:

1. [Specialty/Provider]: [Timeframe]
   - Purpose: [XX]
   - Appointment scheduled: [Yes - date/time / No - patient to call]
   - Phone: [XXX-XXX-XXXX]

2. [Specialty/Provider]: [Timeframe]
   - Purpose: [XX]
   - Appointment scheduled: [Yes - date/time / No - patient to call]
   - Phone: [XXX-XXX-XXXX]

PCP Follow-up: [Within XX days]
   - Provider: [XX]
   - Phone: [XXX-XXX-XXXX]

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PENDING RESULTS AT DISCHARGE:

| Test | Expected Result | Who Will Follow Up |
|------|-----------------|-------------------|
| [XX] | [XX] | [Provider/service] |
| [XX] | [XX] | [Provider/service] |

Note: Patient/family informed that [provider/service] will call with results. If no call within [XX] days, patient should contact [phone number].

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DISCHARGE INSTRUCTIONS:

ACTIVITY:
- [Specific activity restrictions or recommendations]
- [Return to work/driving guidance if applicable]

DIET:
- [Specific dietary instructions]
- [Fluid restrictions if applicable]

WOUND CARE:
- [Specific wound care instructions if applicable]

SYMPTOMS TO MONITOR:
- [Specific symptoms to watch for]
- [When to call doctor vs go to ED]

PATIENT EDUCATION PROVIDED:
- [ ] Diagnosis and treatment explained
- [ ] Medication changes reviewed
- [ ] Follow-up appointments reviewed
- [ ] Warning signs discussed
- [ ] Written instructions provided
- [ ] Patient verbalized understanding
- [ ] Questions answered

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RETURN PRECAUTIONS:

Return to ED or call 911 if you experience:
- [Specific symptom 1]
- [Specific symptom 2]
- [Specific symptom 3]
- Fever > 101.5F
- Any other concerning symptoms

Call your doctor if you experience:
- [Less urgent symptom 1]
- [Less urgent symptom 2]
- Questions about medications

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DISPOSITION:
Discharged to: [Home / SNF / Rehab / LTACH / Hospice]
Services arranged: [Home health / PT / OT / VNA / None]
Equipment ordered: [Walker / O2 / Hospital bed / None]
Transportation: [Private vehicle / Ambulance / Medical transport]

CODE STATUS AT DISCHARGE: [Full code / DNR / DNI / POLST]

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[Provider signature block]
Dictated: [Date/Time]
Transcribed: [Date/Time]

cc: [PCP name]
    [Consulting physician]
    [Other providers]

Why This Works

Medication reconciliation with reasoning: Listing discharge meds is not enough. Categorizing as NEW/CHANGED/STOPPED with explicit reasons prevents the receiving provider from guessing why changes were made and reduces medication errors during transitions.

Pending results accountability: Specifying WHO will follow up on pending results closes a major safety gap. Vague “results pending” notes lead to dropped follow-ups. Explicit assignment creates accountability.

Structured return precautions: Generic instructions like “come back if you feel worse” are unhelpful. Diagnosis-specific warning signs help patients recognize what matters and when to seek care, reducing unnecessary ED visits and delayed presentations.

Filled Example

[SYNTHETIC EXAMPLE - Not a real patient]

DISCHARGE SUMMARY

PATIENT INFORMATION:
Admission Date: [XX/XX/XXXX]
Discharge Date: [XX/XX/XXXX]
Length of Stay: 4 days
Attending Physician: [XX]
Dictating Physician: [XX]

ADMITTING DIAGNOSIS:
1. Acute dyspnea

DISCHARGE DIAGNOSES:
1. Acute decompensated heart failure with reduced ejection fraction (HFrEF), EF 35%
2. Hypokalemia, diuretic-induced, resolved
3. Type 2 diabetes mellitus, controlled
4. Hypertension, controlled

PRINCIPAL PROCEDURE(S):
None performed this admission

CONSULTANTS:
- Cardiology: [XX] - Medication optimization, outpatient follow-up arranged

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BRIEF HOSPITAL COURSE:

PRESENTING HISTORY:
72-year-old male with history of HFrEF (EF 35%), HTN, T2DM who presented with 3-day history of progressive dyspnea, orthopnea, and lower extremity edema. Admitted with BNP 1,850, CXR showing pulmonary vascular congestion. Triggered by dietary indiscretion and missed diuretic doses.

HOSPITAL COURSE BY PROBLEM:

Problem #1: Acute decompensated heart failure
Patient was volume overloaded on admission with elevated JVP, bibasilar crackles, and 2+ peripheral edema. Started on IV furosemide 40mg BID with excellent diuretic response. Achieved net negative fluid balance of 3.8 kg over 3 days. Symptoms resolved, JVP normalized, crackles cleared. Transitioned to oral furosemide 60mg BID on day 3 with continued diuresis. BNP decreased from 1,850 to 520. Cardiology consulted for medication optimization, recommended increasing carvedilol from 12.5mg BID to 25mg BID as outpatient if BP tolerates.

Problem #2: Hypokalemia
Potassium 3.2 on day 2 in setting of aggressive diuresis. Repleted with oral KCl 40 mEq x 2 doses. Normalized to 3.8. Started on standing KCl 20 mEq daily with diuretic. No arrhythmias noted.

Problem #3: T2DM
Continued home metformin. Blood sugars 142-186 during admission on home regimen plus sliding scale. A1c 7.4% (goal ≤8% per ADA 2024 Standards of Care for older adults with comorbidities and limited life expectancy). No medication changes.

DISCHARGE CONDITION:
- Mental Status: Alert and oriented x 3
- Activity Status: Ambulatory - independent
- Diet: Low sodium (2g/day), fluid restriction 1.5L/day

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DISCHARGE MEDICATIONS:

CONTINUED MEDICATIONS (no changes):
1. Metformin 1000mg PO BID
2. Lisinopril 20mg PO daily
3. Carvedilol 12.5mg PO BID (increase to 25mg BID at cardiology f/u if tolerated)
4. Aspirin 81mg PO daily
5. Atorvastatin 40mg PO at bedtime

NEW MEDICATIONS:
1. Potassium chloride 20 mEq PO daily - to prevent hypokalemia with increased diuretic

CHANGED MEDICATIONS:
1. Furosemide 40mg daily -> 60mg PO BID - increased due to volume overload, need for more aggressive diuresis

STOPPED MEDICATIONS:
None

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FOLLOW-UP APPOINTMENTS:

1. Cardiology: 1-2 weeks
   - Purpose: Medication optimization, consider increasing carvedilol
   - Appointment scheduled: Yes - [date] at [time]
   - Phone: [XXX-XXX-XXXX]

2. PCP Follow-up: Within 7 days
   - Purpose: BP check, weight monitoring, recheck BMP
   - Appointment scheduled: No - patient to call Monday
   - Phone: [XXX-XXX-XXXX]

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PENDING RESULTS AT DISCHARGE:

| Test | Expected Result | Who Will Follow Up |
|------|-----------------|-------------------|
| None | - | - |

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DISCHARGE INSTRUCTIONS:

ACTIVITY:
- Resume normal activities as tolerated
- Daily walking encouraged
- Avoid strenuous activity until cardiology follow-up

DIET:
- Low sodium diet (less than 2g sodium per day)
- Fluid restriction: 1.5 liters (about 6 cups) per day maximum
- Avoid processed foods, restaurant meals, canned soups

DAILY MONITORING:
- Weigh yourself every morning after urinating, before eating
- Call doctor if weight increases >3 lbs in one day or >5 lbs in one week

PATIENT EDUCATION PROVIDED:
- [X] Diagnosis and treatment explained (heart failure exacerbation)
- [X] Medication changes reviewed (increased Lasix, added potassium)
- [X] Follow-up appointments reviewed
- [X] Warning signs discussed (weight gain, swelling, shortness of breath)
- [X] Written instructions provided
- [X] Patient verbalized understanding
- [X] Questions answered

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RETURN PRECAUTIONS:

Return to ED or call 911 if you experience:
- Severe shortness of breath or unable to breathe lying flat
- Chest pain or pressure
- Confusion or difficulty speaking
- Fainting or near-fainting

Call your doctor if you experience:
- Weight gain >3 lbs in one day or >5 lbs in one week
- Increased swelling in legs or ankles
- Worsening shortness of breath with activity
- Dizziness when standing (may indicate blood pressure too low)
- Questions about medications or diet

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DISPOSITION:
Discharged to: Home
Services arranged: VNA for CHF monitoring (visits 2x/week x 2 weeks)
Equipment ordered: Scale for daily weights
Transportation: Private vehicle with family

CODE STATUS AT DISCHARGE: Full code

Checklist

  • Admission and discharge diagnoses are specific and billable
  • Hospital course summarizes each problem addressed
  • All medication changes listed with reasons (NEW/CHANGED/STOPPED)
  • Follow-up appointments scheduled or clear instructions to schedule
  • Pending results listed with responsible provider for follow-up
  • Return precautions are diagnosis-specific
  • Patient education documented with understanding confirmed
  • Discharge disposition and services clearly documented
  • PCP and relevant providers cc’d on summary

Last reviewed: 2026-01-20. Clinical content based on society guidelines, FDA labeling, and pivotal trials available at review date. Verify against current sources before clinical use.