Student Discharge Summary Draft

STUDENT DRAFT—FOR ATTENDING FINALIZATION

(This is a medical student draft requiring supervising clinician review and authentication prior to transmission. Do not send to patient or outside clinicians until finalized by the attending.)

• Patient Name: [Full legal name]
• MRN: [Medical record number]
• DOB: [MM/DD/YYYY]
• Admission Date: [MM/DD/YYYY]
• Discharge Date: [MM/DD/YYYY]
• Attending Physician: [Name, credentials]
• Primary Care Clinician: [Name / none / unknown]
• Discharge Destination: [Home / Home with services / SNF / Acute rehab / LTACH / Other: specify]
• Code Status: [Full code / DNR / DNI / Other: specify]
• Allergies: [Drug allergies with reaction type / NKDA]

Discharge Snapshot

[3–6 sentence synopsis: reason for admission; major diagnoses or procedures; key clinical changes; discharge destination and condition; most important follow-up tasks or pending results.] (Keep concise so a receiving clinician can understand the hospitalization without reading the full note.)

Admission Diagnosis

[Working diagnosis or chief concern at admission] (Use language as documented on admission; often symptom-based.)

Discharge Diagnoses

• [Principal discharge diagnosis]
• [Secondary diagnoses addressed during hospitalization]
• [Relevant chronic comorbidities affecting follow-up]

(List in order of clinical importance. Include only conditions evaluated or managed during the stay. If the diagnosis remains uncertain, state this explicitly with the planned outpatient evaluation.)

Significant Findings and Key Studies

• [MM/DD: Test/study name — one-line actionable result summary; state follow-up action for incidental findings and who is responsible]
• [MM/DD: Procedure — key findings and outcome]
• [MM/DD: Microbiology/pathology — organism or diagnosis with susceptibility or relevant details]
• [MM/DD: Pertinent lab trends — concise trend with clinical relevance]

(Include normal results only if they resolve a key diagnostic question. Omit routine normal labs and large tables.)

Hospital Course by Problem

(Order by acuity and patient safety risk, then chronic conditions requiring active outpatient management. Problem names should align with discharge diagnoses.)

[Problem 1: Diagnosis or clinical impression]

[Presentation and key diagnostics; therapies and interventions with dates; clinical response; status at discharge; discharge plan including follow-up needs and related medication changes.]

• Complications: [Hospital-acquired infections, adverse drug reactions, falls, delirium, AKI, bleeding, procedural complications, or escalation of care] (Include only if applicable; omit this line if none.)
• Status at Discharge: [Resolved / Improved / Stable / Worsened] — [Objective parameters if relevant]
• Discharge Plan: [What to monitor, specific tests needed, timeframe, responsible clinician]

(If the working diagnosis evolved, document: "Admitted for presumed [X]; ultimately diagnosed as [Y] based on [Z].")

[Problem 2: Diagnosis or clinical impression]

(Repeat structure for each additional problem.)

Condition at Discharge

[Clinical stability; mental status if relevant to self-management; functional status or mobility vs. baseline; oxygen requirements; wound status; lines or drains; planned services such as home health, PT/OT, DME.]

Discharge Medications

Medication Reconciliation Status: [Completed with patient/caregiver on MM/DD/YYYY / In progress — specify what is needed] (Must always be stated.)

New

• [Medication — dose, route, frequency — indication — duration/end date — monitoring requirements]

Changed

• [Medication — new dose, route, frequency — reason for change — monitoring requirements]

Continued

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

Stopped

• [Medication — rationale for discontinuation]

High-Risk Medication Documentation (Include only medications that apply.)

• Anticoagulants: [Agent; indication; intended duration/end date; monitoring plan; follow-up provider]
• Insulin/Diabetes agents: [Dosing plan; hypoglycemia precautions; glucose monitoring instructions]
• Opioids/Benzodiazepines: [Indication; dosing limits; safety counseling; naloxone if applicable; taper plan]
• Antibiotics: [Agent; total course length; start and stop dates; adverse effect monitoring]
• Diuretics/RAAS inhibitors: [Dose; electrolyte/renal monitoring plan and timing]

(If any medication information is incomplete, use "[verify on discharge orders]" rather than guessing.)

Follow-Up and Outstanding Care Needs

• Who: [Clinician/service] — When: [Date or timeframe] — Why: [Clinical question/task] — What: [Labs/imaging/symptom assessment] — Responsible: [Name/service to ensure completion]

(Avoid vague instructions. If specifics are unknown, state the clinical intent and recommended timeframe.)

Pending Tests and Studies

• [Test name — Date collected — Expected turnaround — Responsible clinician — How patient will be notified]

(If no tests are pending, state: "No pending tests at discharge." This section must never be left blank.)

Discharge Instructions

(Patient-facing; use plain language without medical abbreviations. If a separate patient instruction document will be generated, abbreviate to high-risk elements only: medication changes, red flags, and responsibility for pending results.)

• Diagnosis Explanation: [Lay-language summary of the condition(s) and hospital care]
• Medications: [What changed, how to take them, when to call for problems]
• Appointments: [Dates/times or timeframes; location; what to bring]
• Diet and Activity: [Dietary recommendations; activity level; restrictions]
• Wound/Equipment Care: [Step-by-step care instructions if applicable]
• Red-Flag Symptoms: [Specific symptoms — when to call clinic — when to seek emergency care]
• Contact Information: [Clinic phone; after-hours instructions]

Patient Understanding: [Instructions reviewed with patient/caregiver and understanding confirmed / Pending — specify plan]

Attestations

Student Attestation:
This discharge summary draft was prepared by [Student Name], [Role], under the supervision of [Attending Name]. This document requires attending review, verification, and authentication prior to finalization.

Supervising Clinician Attestation:
[Space for attending to verify accuracy, make edits, and authenticate with signature, date, and time]

(Documentation guidance: Attribute uncertain or secondhand information with "per patient," "per chart review," or "per consult note." Do not infer diagnoses or complications unless explicitly documented. Use explicit dates for admission, discharge, major procedures, key tests, and antibiotic courses. If required information is unavailable, use a bracketed placeholder rather than omitting safety-critical elements.)