Discharge Summary (Neurosurgery)

Patient name: [Patient name]
MRN: [Medical record number]
DOB: [Date of birth]   Age: [Age]   Sex: [Sex]
Admission date/time: [Admission date and time]
Discharge date/time: [Discharge date and time]
Attending neurosurgeon: [Attending neurosurgeon]
Operating surgeon(s): [Operating surgeon(s) / Same as attending]
Admitting service: [Admitting service]
Discharging service: [Discharging service]
Discharge disposition: [home / home with services / acute rehab (IRF) / SNF / LTACH / hospice / other: specify]
Code status at discharge: [Full code / DNR / DNI / DNR-DNI / other: specify]

Summary

(Provide a 2–6 line, high-yield synopsis so a covering clinician can grasp the case without reading further.)

• [Primary neurosurgical diagnosis]
• [Key procedure(s) with date(s)]
• [Significant inpatient complications / None]
• [One-line neurologic status at discharge]
• [Critical follow-up needs: staple/suture removal window, timing of postop imaging, anticoagulation/antiplatelet restart plan, device settings, therapy needs]

Admission Diagnosis

[Reason for hospitalization, presenting symptom or event, working diagnosis at admission, and relevant context such as mechanism for trauma, symptom timeline, or pivotal pre-hospital imaging findings] (For elective postoperative admissions, state the planned procedure as the indication. Limit to 1–2 sentences.)

Discharge Diagnoses

(List in order: primary neurosurgical diagnosis first, then major inpatient complications, then comorbidities that affected care. Include postoperative state as applicable. If final diagnosis pending, state interim diagnosis and note that confirmation is pending with follow-up plan.)

• [Primary neurosurgical diagnosis]
• [Postoperative state, e.g., s/p procedure and levels/site]
• [Major inpatient complication(s), if any]
• [Relevant comorbidities that affected care]

Procedures

(List each procedure performed. If none performed, explicitly state "No procedures performed." Do not infer "uncomplicated" unless explicitly documented. If operative details unavailable, note this and reference the dictated operative report.)

• Date: [Date] — Procedure: [Procedure name] — Surgeon(s): [Name(s)] — Approach/site/levels: [Details, for spine cases]

  • [Indication]
  • [Key intraoperative findings]
  • [Implants/devices placed: clips, coils, stents, shunt type and setting, spinal hardware levels]
  • [Estimated blood loss and transfusions, if clinically relevant]
  • [Intraoperative complications / None]
  • [Specimens sent and status]
• (Repeat for additional procedures as needed.)

Significant Findings

(Summarize key objective data that drove management. Omit entirely normal results unless documenting a negative workup is clinically important.)

• Imaging:
  • [Modality and region, date: concise interpretation relevant to neurosurgical decision-making]
  • [Postoperative imaging, date: expected versus unexpected findings and implications]
• Laboratory trends:
  • [Pertinent abnormal values and trends: sodium, WBC, hemoglobin, INR, inflammatory markers, cultures]
• Other studies: [EEG results if seizures or altered mental status; culture results with organism and susceptibilities; other relevant studies] (Omit section if none.)
• Pathology: [Specimen type and final diagnosis / Pending — responsible clinician and communication plan] (Omit if no specimens sent.)

Hospital Course

(Organize by problem, highest clinical severity first. For each problem, briefly summarize the course, key interventions and response, status at discharge, and related discharge plan items. Avoid day-by-day chronology unless necessary. Include only applicable problem categories.)

• Primary neurosurgical problem:
  • [Concise course and interventions]
  • [Status at discharge: resolved / improving / persistent]
  • [Related discharge plan items]
• Neurologic complications: [seizures / vasospasm / hydrocephalus / cerebral edema / CSF leak / other]
  • [Course, interventions, response]
  • [Status at discharge and plan]
• Medical complications: [infection / VTE / cardiopulmonary / electrolytes / other]
  • [Course, interventions, response]
  • [Status at discharge and plan]
• Pain management:
  • [Analgesic regimen and response]
  • [Opioid plan and bowel regimen at discharge]
• Disposition planning:
  • [PT/OT/SLP evaluations and recommendations]
  • [Equipment and services arranged]

Complications

(List surgical and medical complications with date, management, and status at discharge. If none occurred, state "None known.")

• [Complication: date — management — status at discharge]

Devices and Implants

(Document all relevant devices. If none, state "No drains or devices at discharge.")

• External drains removed: [EVD / lumbar drain / subgaleal / wound drain: placement date — removal date — condition at removal]
• Implanted devices:
  • [VP/VA shunt: type and valve setting]
  • [Aneurysm clip/coil/stent: device type and location]
  • [DBS hardware: targets, laterality, settings]
  • [Spinal instrumentation: construct and levels]
  • [Cranioplasty/bone flap: status and material]
• Wound closure: [Closure type; staple/suture removal due date]

Neurologic Status at Discharge

(Provide a standalone neurologic exam at discharge. If an element cannot be assessed, state why. Include spine-specific or lesion-specific elements only when applicable to the case.)

• Mental status: [Alertness and orientation]
• Speech/language: [Fluency, comprehension, naming, repetition]
• Cranial nerves: [Deficits or intact]
• Motor: [Global strength or key muscle groups; asymmetries]
• Sensory: [Light touch, pain, proprioception; focal deficits]
• Coordination: [Finger-nose, heel-shin; dysmetria]
• Gait: [Observed / assisted / not tested: reason]
• Seizure status: [Last seizure date / No seizures during admission]
• Spine cases: [Bowel/bladder function; radicular symptoms; myelopathy signs] (Include for spine cases only.)
• Focal deficits and trajectory: [Details] (Include for brain tumor or vascular cases.)

Functional Status at Discharge

• Overall condition: [stable / improved / guarded] — [brief qualifier]
• Mobility: [independent / supervision / assist level] with [assistive device]
• Therapy: [PT/OT/SLP recommendations and frequency]
• Diet/swallow: [Diet level; aspiration precautions if any]
• Pain control: [Adequacy and regimen]
• Nursing needs: [Wound care, drain care, collar/brace management]

Discharge Medications

Complete medication list: [Full reconciled discharge medication list with dose, route, frequency, and indication]

Medication changes:

• New: [Medication — indication — planned duration or stop date]
• Changed: [Medication — change — rationale]
• Discontinued: [Medication — rationale]
• Held: [Medication — restart date or criteria — responsible clinician]

Neurosurgery-specific guidance: (Include only applicable items.)

• Antiepileptics: [Indication; planned duration if prophylactic; taper plan]
• Steroids: [Taper schedule; GI prophylaxis]
• Anticoagulants/antiplatelets: [Hold duration and restart timing; bridging plan if any]
• Opioids: [Expected duration; bowel regimen]
• Antibiotics: [Indication; culture status; stop date]
• VTE chemoprophylaxis: [Discharge plan and timing]

Discharge Instructions

(Keep concise. Reference separate patient instruction documents if detailed handouts were provided.)

• Activity: [Cranial precautions: lifting, straining, driving, seizure precautions] or [Spine precautions: no bending/lifting/twisting; brace/collar use]
• Wound care: [Dressing, bathing, shampooing guidance; signs of infection; staple/suture removal timing]
• DVT prevention: [Ambulation goals; compression devices if prescribed]
• Diet/hydration: [Guidance]
• Bowel regimen: [Agents and targets]
• Equipment/services: [DME provided; home health; outpatient therapy]

Follow-Up Plan

(List each item with provider, timeframe, purpose, and whether scheduled or to be scheduled with responsible party.)

• Neurosurgery: [Timeframe] — [Purpose: wound check, staple removal, imaging review, pathology review] — [scheduled / to be scheduled by: responsible party]
• Imaging: [Modality] — [Timeframe and location] — [scheduled / to be scheduled by: responsible party]
• Primary care: [Timeframe] — [Issues to address] — [scheduled / to be scheduled]
• Subspecialty: [Service] — [Timeframe and purpose] — [scheduled / to be scheduled]
• Rehabilitation: [PT/OT/SLP] — [Frequency] — [scheduled / to be scheduled]
• Labs: [Which labs; when; who will review and communicate results]

Pending Results

(List each pending result with test, indication, expected availability, responsible party, and communication plan. If none, state "No pending results at discharge.")

• [Pending test — indication — expected date — responsible clinician — communication plan]

Return Precautions

(Provide neurosurgery-specific warning signs relevant to the case type.)

• Cranial warning signs: New or worsening weakness, speech changes, confusion, seizure, severe or worsening headache, vision changes, difficulty waking, fever, wound redness/swelling/drainage, clear fluid from incision/nose/ear
• Spine warning signs: New numbness or weakness in extremities, loss of bowel or bladder control, severe uncontrolled pain, fever, wound redness/swelling/drainage
• VTE warning signs: Shortness of breath, chest pain, calf swelling/warmth/redness
• What to do: For severe symptoms or concern for stroke/PE — call 911 or go to nearest ED. For non-emergent concerns — call neurosurgery clinic at [clinic phone number] during business hours or hospital operator after hours.