Trauma Discharge Summary

Patient Name: [Patient full name] MRN: [Medical record number] DOB: [Date of birth]

Admission Date/Time: [Admission date and time] Discharge Date/Time: [Discharge date and time]

Discharging Service: [Service] Attending of Record: [Attending physician]

Primary Trauma Diagnosis: [Primary trauma diagnosis]

Mechanism of Injury: [Mechanism of injury with date/time if known; "Unknown" if uncertain]

Code Status at Discharge: [Full Code / DNR / DNI / POLST-based / Other]

Primary Care Clinician: [Name and contact, or "Unknown/Not on file"]

Receiving Facility/Clinician: [Facility name, location, accepting clinician/service] (Include only for transfers; otherwise omit this line)

Discharge Diagnoses

Final Injury List

(Provide reconciled final injury list organized by body region: Head/Neuro, Face, Spine, Chest, Abdomen/Pelvis, Extremities, Skin/Soft Tissue, Vascular. Include only regions with injuries. For each injury: name with laterality/level, grade/classification if applicable, operative vs non-operative, status at discharge, follow-up service.)

• [Body region]: [Injury; laterality/level; grade/classification; operative vs non-operative; status at discharge; follow-up service]

Active Comorbidities

• [Comorbidity and relevance to ongoing care]

Complications During Hospitalization

(List complications with dates and current status. If none, state "Complications: None.")

• [Date] — [Complication] — [Current status]

Procedures

(If no procedures, state "Procedures: None.")

Operative:

• [Date] — [Procedure; laterality] — [Key implants/devices] — [Surgeon/Service]

Non-operative:

• [Date] — [Procedure/device] — [Current status: removed vs present] — [Pending pathology/cultures if applicable]

Consultations

(Each consultant should have corresponding Follow-up Plan entry)

• [Consulting service]: [Key discharge-relevant recommendations including restrictions, medication changes, follow-up timeframe]

Hospital Course

(Create one subsection per major injury or problem. Synthesize for an external clinician without requiring full chart review.)

[Problem/Injury title]

Course: [Hospital management summary including imaging, procedures, complications]

Status at Discharge: [Current clinical status and exam findings]

Discharge Plan: [Restrictions, related medications, wound/device care, follow-up]

Pertinent Results

(Include only results needed for safe continuity)

Key Imaging:

• [Date] — [Study] — [Finding] — [Clinical implication]

Key Labs/Microbiology:

• [Date] — [Test/result] — [Monitoring need or treatment implication]

Incidental Findings: (If none: "Incidental findings requiring follow-up: None identified.")

• [Finding] — [Recommended follow-up modality and timeframe] — [Responsible service]

Condition at Discharge

Clinical Status: [Hemodynamic stability; respiratory status; pain control; diet tolerance; mentation/GCS if TBI]

Functional Status: [Ambulation level; ADL needs; PT/OT/SLP recommendations; cognitive deficits if applicable]

Equipment/Services Arranged: [DME, home health, rehab placement, caregiver support as applicable]

Discharge Disposition

[Home / Home with services / Acute rehab / SNF / LTACH / Transfer to another hospital / Jail-prison / AMA]

[Destination facility name and location if not home; accepting clinician/service for transfers]

Discharge Medications

(Complete reconciled list with changes clearly identified. If no changes: "No changes to home medications.")

New:

• [Medication] — [Dose/route/frequency] — [Duration/end date] — [Indication]

Changed:

• [Medication] — [Change details] — [New dose/route/frequency] — [Indication]

Stopped:

• [Medication] — [Reason]

Continued home medications:

• [Medication] — [Dose/route/frequency]

High-risk medication guidance: (Include only categories applicable to this patient)

• Opioids: [Daily maximum; taper plan if applicable; bowel regimen]
• Anticoagulation: [Indication; duration; monitoring plan; managing service]
• Antibiotics: [Indication; total duration; end date; pending culture plan]
• VTE prophylaxis: [Agent; dose; duration]

Discharge Instructions

Activity and Weight Bearing: [Activity level; lifting/driving/contact sport restrictions] [Weight-bearing status per limb, e.g., "NWB LLE," "WBAT all extremities"] [ROM or spine/brace precautions] (Weight-bearing status must be explicitly stated—if unclear, document "WB status requires clarification prior to discharge")

Diet: [Diet type and restrictions]

Wound Care:

• [Location] — [Dressing type; change frequency] — [Showering guidance] — [Staple/suture removal timing] — [Infection warning signs]

Device Care: (If no devices: "No drains, lines, or devices at discharge.")

• [Device type and location] — [Care instructions] — [Output thresholds for calling] — [Removal plan; responsible service]

Return Precautions: Seek care if:

• [Diagnosis-specific warning signs tailored to patient's injuries]

Follow-up Plan

(Organized by urgency. Every consultant should have corresponding entry. If not yet scheduled, state "Not scheduled—patient to call within [timeframe].")

Within 48–72 hours:

• [Service/Clinician] — [Reason] — [Location/contact] — [Pre-visit tests if needed]

1–2 weeks:

• [Service/Clinician] — [Reason] — [Location/contact] — [Pre-visit tests if needed]

4–6 weeks:

• [Service/Clinician] — [Reason] — [Location/contact] — [Pre-visit tests if needed]

Pending Studies

(If none: "Pending studies: None.")

• [Test] — [Date ordered] — [Expected timing] — [Responsible clinician] — [Communication plan]