Neurology Discharge Summary

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB / Age: [Date of birth / age]

Sex: [Sex]

Admission Date: [Admission date]

Discharge Date: [Discharge date]

Length of Stay: [Number of days]

Admitting Service: [Admitting service]

Discharging Service: [Discharging service]

Attending Physician: [Attending physician name and credentials]

Discharge Disposition: [home / SNF / IRF / LTACH / hospice / transfer / AMA / expired]

Summary

• [One-line reason for admission with timeframe]
• [Principal neurologic diagnosis] [confirmed / probable / suspected / pending workup] (Include key differentials ruled out)
• [Major interventions performed]
• [Critical study findings that drove decisions]
• [Neurologic trajectory: improved / stable / worse] [NIHSS and/or mRS if stroke patient]
• [Discharge destination and key follow-up needs]

(Include 3–6 bullets; keep each to one concise sentence)

Reason for Hospitalization

[Chief neurologic complaint with onset timing or last known well] [Key exam findings on presentation including localizing deficits and mental status] [Immediate stabilization decisions] [Relevant background impacting risk or management] (Include brief patient quotes only if they clarify symptom quality or timing; keep to a single short paragraph)

Discharge Diagnoses

Primary diagnosis: [Specific neurologic diagnosis with etiologic framing] [confirmed / probable / suspected / pending workup]

Secondary diagnoses: [Secondary diagnoses and comorbidities affecting care, or "None"]

(Use ICD-friendly specificity; label diagnostic uncertainty explicitly)

Key Studies & Results

(Include only studies that informed diagnosis, management, or require follow-up; format each as: Date – Modality – One-line impression with key measurements)

Neuroimaging: [CT/CTA/MRI/MRA results with dates and key findings]

EEG/Neurophysiology: [EEG type, date range, seizure burden, epileptiform activity, background summary]

CSF Studies: [Opening pressure, cell count, protein/glucose, cultures, pending panels]

Other Diagnostics: [TTE/TEE, telemetry, carotid duplex, pertinent labs with key findings]

Pending Studies: [Test name, expected turnaround, responsible clinician]

(Omit categories with no relevant studies)

Procedures

• [Date] – [Procedure] – [Outcome] – [Complications if any]

(Omit this section entirely if no procedures were performed)

Hospital Course

(Organize by problem in descending clinical impact; emphasize decisions and rationale rather than day-by-day recounting; document reasons for major decisions explicitly)

[Problem 1]

[Assessment summary: diagnosis and how confirmed in 1–3 sentences]

• Key management: [Dated events, interventions, and rationale]
• Status at discharge: [resolved / improved / stable / worse]
• Discharge plan: [Medications, monitoring, precautions, outpatient follow-up]

[Problem 2]

(Repeat structure for additional problems as applicable; include consultations obtained and any complications within relevant problem sections)

Condition at Discharge

[Overall clinical stability and neurologic trajectory] [Swallowing/aspiration risk] [Pain control status] [Cognition/behavioral considerations if applicable]

Focused Neurologic Examination

• Mental status: [Level of consciousness, orientation, attention]
• Speech/language: [Fluency, comprehension, naming, dysarthria]
• Cranial nerves: [Pupils, EOM, facial symmetry]
• Motor: [Strength by major groups, pronator drift]
• Sensory: [Light touch, proprioception as tested]
• Coordination: [Finger-nose-finger, heel-knee-shin]
• Gait: [Gait assessment or "deferred" with reason]
• NIHSS: [Score] (Stroke patients)
• mRS: [Score] (Stroke patients)

(If discharge exam not performed, state reason and reference most recent exam with date)

Functional Status & Disposition

• Baseline vs discharge function: [Mobility, ADLs, cognitive-communication status]
• Therapy assessments: [PT/OT/SLP summaries and recommendations]
• Swallow evaluation and diet: [Result and diet texture]
• DME needs: [Assistive devices]
• Discharge destination: [Home / SNF / IRF / LTACH] [Home services or rehab rationale]
• Caregiver availability: [Support persons and training provided]
• Lines/tubes/devices: [Type and care instructions, or "None"]
• Code status: [Full / DNR / DNI / other]

Discharge Medications

Medication List

• [Medication] – [Dose] – [Route] – [Frequency] – [Indication for high-risk medications] (Include start date for new meds; stop date and taper schedule where applicable)

Medication Changes

• New: [Medication and rationale]
• Changed: [Medication, change made, and rationale]
• Stopped: [Medication and rationale]
• Continued: [High-risk medications with rationale]

(For anticoagulants, antiplatelets, AEDs, and immunotherapies, include monitoring parameters and counseling points; document reconciliation method if outpatient history was incomplete)

Stroke Quality Measures

• Antithrombotic at discharge: [Agent or contraindication]
• High-intensity statin: [Agent or contraindication]
• Anticoagulation for AF/flutter: [Agent or contraindication / not applicable]
• Stroke education documented: [Topics covered]

(Include this subsection for stroke patients only)

Follow-Up Plan

• [Date/timeframe] – [Clinician/service] – [Purpose]
• Outpatient testing: [Labs, imaging, EEG, cardiac monitoring] – [Timeframe] – [Ordering responsibility]

Pending Results

• [Test name and specimen] – [Date collected] – [Expected turnaround] – [Clinical significance] – [Responsible clinician for follow-up]

(If none, state "No pending results at discharge")

Patient Education & Return Precautions

Education provided: [Diagnosis explanation, medication instructions, safety counseling] (For stroke: document warning sign education; for seizure: document driving restrictions and seizure precautions counseling)

Return precautions:

• New or worsening neurologic symptoms (weakness, numbness, speech/vision changes, severe sudden headache)
• Seizure recurrence, prolonged seizure, or repeated seizures without recovery
• Fever with neck stiffness, severe headache, or altered mental status
• Signs of medication toxicity or allergic reaction
• [Diagnosis-specific red flags]