Acute Care Discharge Summary (Adult)

Patient: [Full name], [MRN], [DOB]

Admission: [Date and time]

Discharge: [Date and time]

Attending: [Name]

Discharging Clinician: [Name and direct contact]

PCP: [Name and contact / unknown or not on file]

Disposition: [home / SNF / rehab / LTACH / transfer / expired / AMA]

Code Status: [Status at discharge] (Note if changed during stay)

Discharge Summary

[Brief narrative summary: reason for admission, key diagnoses and major interventions, significant complications if any, status at discharge, and most important follow-up needs or pending results] (3–6 sentences focusing on clinical decisions and outcomes rather than day-by-day events)

Reason for Admission

[Presenting problem and clinical context] (1–2 sentences; for observation stays, explicitly state "observation" and the monitoring or diagnostic intent)

Discharge Diagnoses

Principal Diagnosis: [Single principal diagnosis]

Secondary Diagnoses:

• [Diagnosis with clinically relevant modifiers]
• [Additional diagnosis]
• [Additional diagnosis]

(Include condition status such as acute/chronic, severity, or complications. If uncertain, document as suspected/probable with planned outpatient workup.)

Hospital Course

(Organize by clinical problem in descending order of importance. Align problem names with diagnoses list.)

[Problem 1]: [Key findings and decisive diagnostics; treatments provided with rationale; clinical trajectory and response; status at discharge: resolved/improving/ongoing; explicit next steps for receiving clinician]

[Problem 2]: [Summary as above]

[Problem 3]: [Summary as above]

(Add additional problems as needed)

Procedures

(Include only if procedures were performed; omit entire section if none)

• [Procedure name] — [Date]: Indication: [reason]. Findings: [key findings]. Complications: [none / description]. Pathology/microbiology: [final result / pending with expected timeframe].
• [Additional procedure]

Consultations

(Include only if consultations occurred; omit entire section if none)

• [Consulting service] — [Date(s)]: [Discharge-relevant recommendations only]. Follow-up: [if requested, specify provider, timeframe, and responsibility for arranging].
• [Additional consultation]

Discharge Medications

• [Medication (generic)] — [dose] [route] [frequency]; Indication: [reason]; Duration: [time-limited / ongoing]; [Special instructions if any: taper, hold parameters, max daily dose]
• [Medication]
• [Medication]

Medication Changes:

• New: [Medication] — Indication: [reason]. Monitoring: [labs/symptoms/timing].
• Changed: [Medication] — [Change description] due to [rationale].
• Stopped: [Medication] — Reason: [rationale]. Alternative: [if applicable].

(If no changes in a category, omit that line)

Allergies: [Drug and reaction type / NKDA / allergy history unknown]

Pending Results

(This section must not be left blank)

• [Test name] ([Date obtained]) — Pending: [what is pending]. Expected: [timeframe]. Responsible: [clinician/service]. Action if abnormal: [plan].
• [Additional pending study]

(If no pending studies, state: "Pending results: none.")

Follow-Up Plan

Appointments:

• [Provider/service] — [Purpose]; [Target timeframe or scheduled date]; Scheduling: [clinic / patient / to be arranged by discharge team]
• [Additional appointment]

Post-Discharge Monitoring:

• [Test and timing] — [Clinical reason]

Home Services/DME: [Home health / PT / OT / wound care / oxygen / mobility aids as applicable] (Include frequency and oversight responsibility)

Activity/Diet Restrictions: [Restrictions and duration / none]

Return Precautions

• Call 911 for: [Life-threatening symptoms such as chest pain, severe shortness of breath, fainting, new one-sided weakness]
• Go to ED for: [Fever ≥100.4°F, worsening symptoms, inability to take oral medications, condition-specific warnings]
• Call clinic for: [Condition-specific concerns, medication questions, follow-up scheduling issues]

(If separate After Visit Summary provided to patient, reference it for complete instructions)

(Global: Summarize key clinical decisions rather than copying progress notes. For Discharge Medications, Allergies, and Pending Results, never leave blank—use explicit "none" or "unknown" when applicable.)