Discharge Summary Writing Ideas

Structure & Format

• SBAR format - Situation, Background, Assessment, Recommendation; keeps it logical and scannable
• Problem-based layout - List each active problem with its own mini-narrative, rather than a single chronological story
• Header snapshot - Put the one-line diagnosis, key vitals at discharge, and critical follow-up dates right at the top so the receiving provider sees them instantly
• Traffic-light system - Use bold or flags for urgent follow-up items vs. routine ones

Content Essentials

• Reason for admission vs. final diagnosis - Always state both; they often differ
• Significant findings summary - Key labs, imaging, procedures with dates and results
• Hospital course in plain language - What changed, what was tried, what worked
• Medication reconciliation - New meds, stopped meds, dose changes - with reasons for each
• Pending results - Tests sent but not yet resulted; who is responsible for follow-up
• Code status and goals of care - Document clearly, especially for complex or elderly patients

Clarity Tips

• Write for the GP or next provider, not for the specialist - avoid jargon where possible
• Use active voice and short sentences
• Avoid copy-paste blocks from progress notes - they inflate length without adding value
• Include specific numbers (e.g., "HbA1c 9.2% on admission, 7.8% at discharge") rather than vague terms like "improved"

Follow-up Section

• Specific appointment dates, not just "follow up with cardiology"
• Who to call if symptoms recur - with a contact number
• Red-flag symptoms the patient should watch for
• Community services or allied health referrals arranged

Patient-Facing Component

• Consider a parallel plain-English discharge letter for the patient alongside the clinical summary
• Include: what happened, what medicines to take, what to avoid, when to seek help

Quality Improvement Angle

• Peer-review discharge summaries monthly for completeness
• Audit timeliness - summaries sent within 24 hours of discharge have better continuity outcomes
• Use templated prompts for common conditions (e.g., ACS, COPD exacerbation, sepsis) to reduce omissions