Discharge Summary (Surgery)

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [MM/DD/YYYY]

Sex: [Sex]

Admission Date: [MM/DD/YYYY]

Discharge Date: [MM/DD/YYYY]

Length of Stay: [Number of days]

Surgical Service: [Service name]

Attending Surgeon: [Name, credentials]

Discharge Disposition: [home independently / home with services / acute inpatient rehab / skilled nursing facility / long-term acute care hospital / other] (Include facility name and contact if applicable. If not documented, note that disposition should be obtained from the discharge order.)

PCP: [Name, phone, fax] (Include if available.)

Reason for Hospitalization

[1–3 sentence summary of why the patient was admitted. For elective surgery, state the indication and key preoperative diagnosis. For urgent or emergent surgery, include the presenting problem, key diagnostic findings, and rationale for operative intervention.]

Discharge Diagnoses

Primary: [Primary discharge diagnosis]

Secondary/Active Problems: [Secondary diagnoses and active problems affecting care or requiring follow-up]

Postoperative Diagnoses: [List if different from preoperative, otherwise omit]

Postoperative Complications: [List complications as diagnoses if any occurred, otherwise omit]

Procedures Performed

• [MM/DD/YYYY — Procedure name; approach: open/laparoscopic/robotic/endovascular; surgeon: Name. Include clinically relevant adjuncts such as anastomosis, ostomy creation, hardware or mesh placement, stent details, drain placement. Reference operative report for full details.]
• (Add additional procedures in chronological order. Clearly label staged cases and returns to OR.)

Hospital Course

(Organize by clinical importance using short paragraphs. Synthesize the overall course rather than copying daily progress notes. Integrate significant diagnostic findings into relevant problem discussions. Use specific dates and postoperative day notation where helpful.)

Operative and Perioperative Course

[Brief summary of intraoperative findings, deviations from plan, estimated blood loss, transfusions, intraoperative complications, and immediate postoperative disposition.]

Postoperative Recovery

[Narrative summary addressing relevant aspects of recovery: pain management approach and response; respiratory status and oxygen needs; GI function and diet advancement; urinary function and catheter status; mobility, weight-bearing status, and PT/OT involvement; other system-specific issues relevant to the surgery. Focus on systems pertinent to the procedure performed.]

Complications

[For each complication: onset date with POD notation, diagnostic basis, interventions, and status at discharge.] (If no complications occurred, state: No postoperative complications occurred.)

Consultations

[Consulting services involved and key recommendations that persist after discharge.] (Omit if no consultants involved.)

Pathology

[Specimens submitted and final pathology results if available. If results are pending, state what is pending, expected timeframe, and who is responsible for follow-up and communicating results to the patient. Include contingency plans based on possible results. Do not infer benign versus malignant—label preliminary impressions as such.] (Omit this section entirely if no specimens were obtained.)

Condition at Discharge

[Clinical stability, mental status, pain control adequacy, functional status relative to baseline, diet tolerance, and bowel/bladder function.]

Wounds: [Incision status: clean/dry/intact, or describe any drainage, erythema, or concerns]

Drains: [Type, location, and output characteristics for each drain present] (If no drains present at discharge, state: No drains at discharge.)

High-Risk Therapy Readiness: [Patient/caregiver readiness and education for anticoagulation, IV antibiotics, ostomy care, or other complex therapies; supports arranged] (Include only if applicable.)

Disposition and Services

Services Arranged: [Home health nursing, physical therapy, occupational therapy, wound care, ostomy support, infusion services, or other services as applicable] (List only services that were arranged.)

Durable Medical Equipment: [Devices provided or ordered]

Activity Restrictions: [Weight-bearing status, lifting restrictions, driving restrictions, and other activity limitations relevant to care and placement]

Discharge Medications

(Provide a reconciled list. For each medication include name, dose, route, frequency, and indication. For time-limited courses, specify duration or stop date. Include tapering instructions where applicable.)

New

• [Medication — dose, route, frequency — indication — duration/stop date if time-limited]

Changed

• [Medication — new dose/route/frequency — indication — reason for change]

Continue

• [Medication — dose, route, frequency — indication]

Stop

• [Medication — reason for discontinuation]

PRN

• [Medication — dose, route, frequency — indication]

VTE Prophylaxis

[Agent, dose, start date, and duration if pharmacologic prophylaxis prescribed. Include mechanical prophylaxis and ambulation goals when relevant.] (If pharmacologic prophylaxis not indicated, briefly state rationale.)

Follow-up and Pending Items

Appointments:

• [Provider/clinic — date/timeframe — purpose]

Pending Results:

• [Test or result pending — expected timeframe — responsible clinician/team for follow-up]

Planned Outpatient Tasks:

• [Labs, imaging, staple/suture removal, drain removal — date or criteria]

Return Precautions Reviewed: [Warning signs and symptoms that should prompt urgent contact or ED evaluation, as discussed with patient]