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Sample discharge summary format 2026
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- Click ‘Get Form’ to open the Sample discharge summary format in the editor.
- Begin by entering the 'Name of attending' and 'Service' as 'Neonatology'.
- Fill in the patient's name, medical record number, date of birth, sex, date of admission, and date of discharge.
- In the 'History' section, provide the post-discharge name, reason for admission, birth weight, gestational age, and maternal history.
- Document the physical examination details at discharge including weight, head circumference, and length with percentiles.
- Summarize the hospital course by systems. Include pertinent lab results for respiratory, cardiovascular, fluids/nutrition, GI, hematology, infectious disease, neurology, psychosocial observations, and sensory evaluations.
- Conclude with the condition at discharge including prognosis and discharge disposition.
- Finally, enter details for care/recommendations including feeds at discharge, medications prescribed, medical equipment needs, car seat position screening if applicable, newborn screening status and immunizations received.
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What must all discharge summaries include?
The Joint Commission has identified six categories of information to include in discharge summaries: reason for hospitalization, significant findings, procedures and treatments provided, patients condition at discharge, patient and family instructions, and attending physician signature.
What are the 5 ds of discharge?
The Joint Commission (TJC) mandates that a discharge summary be produced for every patient by the hospital provider within 30 days of discharge,4 and include (1) reason for hospitalization; (2) procedures performed; (3) care, treatment, and services provided; (4) discharge condition; (5) information provided to the
What is a good discharge summary?
Conclusion: The key components to include in a discharge summary are the discharge diagnosis, treatment received, results of investigations and the follow up required.
What is my discharge summary?
A discharge summary is a handover document that explains to any other healthcare professional why the patient was admitted, what has happened to them in hospital, and all the information that they need to pick up the care of that patient quickly and effectively.
What is the standard discharge summary?
The National Standard for Patient Discharge Summary Information consists of the seven groups of headings: Patient details, Primary care healthcare professional details, Admission and discharge information, Clinical information, Medication information, Follow up and future management, and Person completing discharge
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People also ask
What are 5 of the key elements of a hospital discharge summary?
A discharge summary is a clinical report prepared by a health professional after a hospital stay or series of treatments. It is often the primary mode of communication between the hospital care team and aftercare providers (e.g. the patients GP).
sample discharge summary
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