Patient Discharge Instructions (Hospital After-Visit Summary)

Patient Name: [Patient name]

Date of Discharge: [Date of discharge]

Facility: [Facility name]

For emergencies, call 911.

Questions about these instructions: [Discharge contact number]

(Use plain language throughout. Prefer short sentences and active voice. Use numerals for all doses and times. Avoid unsafe abbreviations; write units in full. Use leading zeros for doses less than 1, such as 0.5 mg, and do not use trailing zeros. Define unavoidable medical terms briefly in parentheses.)

What We Treated

• [Reason for hospital stay in plain language]
• [Key treatment or procedure that affects home care] (Include simple definitions if needed.)
• [Discharge destination: home / rehab facility / skilled nursing / other] and [support services arranged]
• [Statement about uncertain diagnosis and need for follow-up] (Include only if diagnosis remains unclear.)

Your Medicines

(List specific medication names, not drug classes. Include dose, frequency, and timing anchors such as morning, noon, evening, or bedtime. Include route only if not by mouth.)

Medication Changes

START

• [Medicine name] — [dose] [unit], [frequency] ([timing anchor]). Reason: [plain-language reason].
• (Omit this subsection if no new medicines.)

STOP

• [Medicine name]. Reason: [plain-language reason].
• (Omit this subsection if no stopped medicines.)

CHANGE

• [Medicine name] — Now: [new dose/frequency]; Was: [prior dose/frequency]. Reason: [plain-language reason].
• (Omit this subsection if no changed medicines.)

Current Medicine Schedule

(List all medicines the patient should take now, organized by time of day. Omit any time period with no medicines.)

Morning

• [Medicine name] — [dose] [unit], [frequency]. [Key instruction if needed].

Noon

• [Medicine name] — [dose] [unit], [frequency]. [Key instruction if needed].

Evening

• [Medicine name] — [dose] [unit], [frequency]. [Key instruction if needed].

Bedtime

• [Medicine name] — [dose] [unit], [frequency]. [Key instruction if needed].

As Needed

• [Medicine name] — [dose] [unit] for [symptom trigger]. Maximum: [max frequency or total dose]. Call [contact number] if needed more than [threshold] or symptoms do not improve.

High-Risk Medication Safety

• [Anticoagulant safety instructions and warning signs: unusual bleeding, black stools, severe headache, vomiting blood. State which signs need 911 vs clinician call.] (Include only if taking blood thinners.)
• [Insulin or blood sugar medicine safety: signs of low blood sugar (shaking, sweating, confusion) and high blood sugar (excess thirst, frequent urination), actions to take, when to call.] (Include only if taking diabetes medicines.)
• [Opioid safety: do not mix with alcohol or sedatives, overdose signs (very sleepy, slow breathing), constipation prevention, when to call 911.] (Include only if taking opioids.)

Medication Allergies

• [Medicine name] — [reaction type].
• (If no known medication allergies, write: None confirmed.)

[Medication reconciliation incomplete statement] (Include only if the medication list is not finalized. State that the list is not final and provide a number to call before taking any medicines.)

Next Steps

Follow-up Appointments

• [Clinician name/role] — [date] at [time], [location], [phone]. Reason: [reason]. Prep: [preparation instructions].
• [If not yet scheduled: Schedule by [deadline]. Call [phone]. Reason: [reason].]

Pending Results

• [Test name]. [Clinician/service] will review. You will be notified by [method]. Call [number] if you have not heard by [date].
• (Omit this subsection if no pending results.)

Activity

• [Activity restrictions: lifting limits, driving, return to work/school, fall precautions, assistive device use]
• (Omit this subsection if no restrictions.)

Diet and Fluids

• [Diet type or restriction]. [Salt limit]. [Fluid limit].
• (Omit this subsection if no dietary restrictions.)

Wound or Device Care

• [Wound location]: [Care steps], [dressing change frequency], [bathing instructions], [suture/staple removal timing if applicable], [signs of infection to watch for].
• [Device name]: [Care and troubleshooting], [supplies needed], [when to seek help].
• (Omit this subsection if not applicable.)

Home Monitoring

• [Monitoring task: blood pressure / weight / blood sugar]: Check [frequency], target [range], record and bring to appointments.
• (Omit this subsection if no home monitoring required.)

When to Get Help

Call 911 Now

• Trouble breathing
• Chest pain
• Severe or uncontrolled bleeding
• Fainting or unresponsiveness
• Signs of stroke: sudden numbness or weakness on one side, trouble speaking, sudden severe headache, vision changes

Call Your Clinician Today

• [Urgent symptoms related to this patient's diagnoses or medicines that are not life-threatening]
• [Worsening pain, fever above specified threshold, vomiting, signs of dehydration, wound problems, device problems]
• (Tailor to the patient's specific conditions and treatments.)

Call Within 1–2 Days

• [Non-urgent concerns: questions about medicines, mild side effects, trouble getting supplies or appointments]

When in doubt, call [primary contact number].

Contacts and Resources

• Urgent symptoms (not 911): [Contact name/role], [phone]. Hours: [hours]. After-hours: [instructions].
• Medicine questions: [Pharmacy or nurse line], [phone]. Hours: [hours].
• Scheduling: [Clinic/department], [phone].
• Home health or equipment: [Agency/supplier name], [phone]. (Include only if ordered.)
• Interpreter services or accessible formats: [How to request], [phone].
• Patient portal: [Portal URL] — View this document and message your care team.

(Omit any section or subsection that would be empty. Do not leave placeholders in the final patient-facing document. Convert unknown information into a clear task with a deadline and contact number.)