Emergency Department Observation Discharge Summary

Patient: [Full name]

DOB: [DOB]

MRN: [MRN]

Date: [Encounter date]

Location: [ED / Observation Unit]

Observation Start: [Date and time observation services began] (If unavailable, note "unavailable" rather than omitting.)

Observation End: [Date and time of discharge] (If unavailable, note "unavailable" rather than omitting.)

Total Observation Duration: [Hours and minutes] (Calculate from start and end times; if either timestamp is unavailable, note this.)

Discharge Disposition: [home / home with services / SNF / acute rehab / left AMA / other]

Primary Discharge Diagnosis: [Brief label]

Reason for Observation

[Chief complaint, working diagnosis or diagnostic uncertainty prompting observation, and key risk features] (1–3 sentences. Reference the initial ED H&P rather than duplicating it.)

Observation Course

[Chronological narrative of the observation period including clinical trajectory, treatments provided, serial reassessments with key findings, and timestamps for major events when available] (Focus on what changed during observation and response to interventions.)

Consultations: [none / service consulted and key recommendations] (Omit if none obtained.)

Protocol/Pathway: [chest pain pathway / syncope protocol / TIA pathway / other] (Omit if none used.)

Complications or Adverse Events: [none / description of event]

Disposition Rationale: [Concise rationale linking clinical stability, completed monitoring, and treatment response to support discharge rather than admission]

Key Diagnostic Results

• Laboratory: [Pertinent results with values] (If reviewed but values unavailable, state this rather than omitting.)
• ECG: [Date/time, interpretation, key findings] (Note new vs chronic abnormalities.)
• Imaging: [Study, date/time, impression and critical details] (Distinguish acute from chronic/incidental findings.)
• Other Diagnostics: [Point-of-care tests, bedside ultrasound, specialty studies] (Omit if none.)
• Incidental Findings Requiring Follow-up: [none / finding with recommended follow-up]
• Pending Results: [none / test name, expected availability, who will review, how patient will be contacted]

Final Assessment / Discharge Diagnoses

• [Primary diagnosis]: [Brief phrase indicating evaluation completed and current status]
• [Secondary diagnosis]: [Status or management during observation]

(Order by clinical significance. If diagnosis uncertain, document the leading diagnosis, key differentials, and rationale for safe discharge. Do not imply conditions were ruled out unless supporting evaluation is documented.)

Discharge Criteria Met

• Physiologic stability: [Vitals within acceptable range, no new abnormalities requiring inpatient care]
• Symptom trajectory: [improved / resolved / stable] on [current regimen]
• Functional status: [ambulatory / assistance required]; mentation [at baseline / improved]
• Oral intake: [tolerating / not applicable]
• Observation goals completed: [yes / not applicable] (Serial testing negative, monitoring window completed, no recurrence of concerning symptoms.)
• Follow-up feasibility: [reliable follow-up arranged / barriers identified]

Condition at Discharge

Discharge Vitals: [Time] — BP [value], HR [value], RR [value], Temp [value], SpO2 [value] on [room air / supplemental O2] (If discharge vitals unavailable, document most recent vitals with time and note clinical stability at evaluation.)

Focused Exam: [Targeted exam relevant to presenting problem]

Mental Status: [Alert, oriented, baseline mentation / abnormalities noted] (Note capacity if relevant to discharge safety.)

Discharge Medications

Medication reconciliation performed. Allergy reconciliation [completed / unable to verify].

• New medications: [Medication, indication, dose/route/frequency/duration, key safety counseling] (Include sedation warnings, driving restrictions, bleeding precautions as applicable.)
• Changed medications: [Medication, change details, rationale]
• Stopped medications: [Medication, reason stopped]

(If medication list cannot be reliably retrieved, include a warning rather than generating an incomplete list. Home medications continued without change may be summarized briefly or omitted.)

Follow-up Plan

• Follow-up: [PCP / specialist / clinic] within [24–48 hours / 1 week / timeframe] for [purpose]
• Pending results responsibility: [Test name], expected by [timeframe]; [responsible clinician] will contact patient via [method]. If no contact by [timeframe], patient should [action and contact number].
• Referrals/Services: [none / referrals, home services, therapy ordered]

Return Precautions

• Call 911 or return immediately for: [Trouble breathing, chest pain, fainting, new neurologic symptoms, uncontrolled bleeding, condition-specific high-acuity symptoms]
• Return to ED for: [Worsening or recurrent symptoms, persistent vomiting, fever, inability to tolerate fluids/medications, symptoms not improving as expected]