Most sick patients long for a hospital discharge because the event signifies an improvement in their health. But do you ever wonder how physicians (and the entire nursing care team) ensure that all the medical care given to a patient is recorded and made available for their next outpatient visit? It is simple—the healthcare industry uses discharge summary templates.
If you are looking for samples of discharge summary templates, you have come to the right corner of the Internet. In this article, we will provide tips for creating these templates for your own organization through different downloadable discharge summary samples. We have also included a few health-teaching techniques that the healthcare team may implement to ensure post-hospital discharge patient compliance.
What are discharge summary templates?
In essence, discharge summary templates are documents (usually printed) that contain all the health information pertaining to the patient’s stay at a hospital or healthcare facility. As a summary template, all information is written in brief and concise points. It will also include an intended care plan for the patient after he or she is discharged from the facility. All discharge summary templates and forms are treated as confidential since they are part of the patient’s personal health information and may not be accessed without authorization from the patient, his or her legal representative, or the court.
Most hospitals and clinics have their own formats for their discharge summary templates. Some states and governments may also require public and state-funded health facilities to use a certain discharge form. However, the respective hospitals will have the final say in the specific design template they want to use for the discharge form.
We will primarily focus on discharge summary templates created and used by organizations in the healthcare industry like hospitals, clinics, mental health facilities, and teaching universities. Note that there can be other types of discharge summary templates used in other industries. For example, a discharge summary may also be used in military and para-military organizations. Additionally, note that a discharge summary template is different from a medical report template.
Things to include in discharge summary templates
In some countries, all healthcare facilities are required to fill out a standardized discharge summary template for all their patients. In the United States, there is no single discharge summary form created but most healthcare institutions follow the same guidelines in their discharge summary templates. Listed below are the most important items that should be included in a discharge summary.
- Patient information – Full name, address, date of birth, gender, SSN or other health information number
- Primary physician/s and health care team – Full name of the physician/s treating the patient and their address
- Admission and discharge details – Date of admission, signs, and symptoms exhibited during admission, referral type, hospital name or type, date of discharge, discharge method, date of death (if the patient died)
- Clinical care plan – List of medical and/or surgical care interventions given to the patient, diagnoses, medical alerts, allergies, hypersensitivities, diet, patient’s functional state, immunization status, infection status, etc.
- Medications – List of all medications given to the patient
- Continuing care plan – Health teachings, follow-up outpatient visit daily schedule, diet and therapy recommendations, social care instructions, and required physician actions
Blank Discharge Summary Template
Clinical Discharge Summary Template
Dictation Discharge Summary Template
General Format Discharge Summary Template
Hospital Discharge Summary Template
Uses of discharge summary templates
Physicians are required to write discharge summaries for all their patients whether they recover from their illnesses or not. Aside from being a mandatory sample policy, we have listed below the numerous other uses of discharge summaries that every member of the healthcare team should know.
- For documentation purposes. As mentioned earlier, a discharge summary is created primarily for documentation purposes for the hospital and for the patient. It is a document attesting to the treatment plans that a patient underwent while staying at a healthcare facility. Hospitals use discharge summaries to help streamline the record of the patient’s stay at a hospital. This way, physicians and hospital clerks do not have to store and lug around an individual’s entire patient history every time a physician requests for it. This document, however, is not created solely for the benefit of the hospital. These reasons will be discussed in the next few paragraphs.
- For the continuity of medical and nursing care plans. A physician writes (or dictates) a discharge summary every time his or her patient gets well enough to leave the hospital. But in some cases, patients’ conditions may stabilize but this will not mean that they are fully well or have been completely healed. For example, a person suffering from Stage IV colon cancer may have stabilized after a recent pneumonia flare-up, but this does not mean that the person has been healed from cancer. In these scenarios, the patient (with the authority of the next of kin) may be transferred to a nursing home for palliative care. The physician will still need to write a discharge summary for this person since the patient is leaving the hospital and his medical care. A discharge summary will be the main document that allows the physician to relate the patient’s health history and the different medical and nursing care plans that the patient underwent while under the care of the hospital physician. This ensures that the resident healthcare team at the nursing home will know how to care for the new patient.
- To decrease rehospitalizations. Continuity of care does not only apply to patients transferred to a secondary healthcare facility for palliative or support care. It also applies to patients who have recovered from their illnesses, but will still need to be continually monitored to prevent a recurrence of the disease. By creating and using a discharge summary, physicians may still guide their patients’ health status while they recuperate at home. This action helps reduce readmission to hospitals because patients are taught what to do while they are at home. An example is teaching the patient breathing exercises to help decrease pain and reliance on pain medications after hip surgery.
- To provide an accurate picture of the patient’s health status. Another important use of a discharge summary is to provide an accurate picture of the patient’s health status before, during, and after his or her hospitalization. Depending on a state’s or a hospital’s policies, a discharge summary should include concise snapshots of the key events during the patient’s treatment process. In a way, a discharge summary may look like an abridged version of a doctor’s entire healthcare plan. A discharge summary is useful to auditors, other physicians, nurses, lawyers, and other members of the healthcare team since it lets them know the medical interventions done for the patient and how they can proceed with their own care plans for the patient.
- To facilitate hospital recovery audits. In the United States, hospital discharge summaries are very important in making sure that hospitals and healthcare providers receive what they are due in terms of Medicare and Medicaid payments. (Other countries may have another system and name for this service.) A recovery audit is done by government-contracted recovery auditors. They investigate thousands of discharge summary templates each day and spot discrepancies on the payments provided, the patient claims, and the treatment provided to the patient. To illustrate, a patient may have been admitted with an initial diagnosis of irritable bowel syndrome and was promptly treated. However, upon discharge, the doctor’s diagnosis was gastritis. Hospital staff who process the Medicare and Medicaid claims for these admissions may be confused about the actual diagnosis. This can then lead to issues during hospital recovery audits and, ultimately, to decreases in hospital revenue.
National Standard for Patient Discharge Summary Template
Nursing Home Discharge Summary
Pediatric Discharge Summary Template
Psychiatric Facility Discharge Summary Template
Sample Discharge Summary Template
Health teachings during the patient discharge process
One of the main benefits of creating discharge summaries is that it allows the physician (and the entire healthcare team) to create a holistic treatment plan for the patient even after their contact with the patient ends. This is primarily done by providing the patient (and his/her significant other) with applicable health teachings. When done right and with the patient’s cooperation, you can almost always guarantee fast recovery and decrease the risk of recurrence of the illness.
- Teach proper medication handling. Most patients who are discharged from a hospital will still need to follow a medication regimen weeks after they leave the hospital. Teaching a patient to adhere to his or her medication list regimen religiously often falls into the hands of the nurse or a nursing associate. Often, it may be better to also teach the patient’s spouse or caretaker when and how to administer the medications in case the patient is unable to do it himself or herself. To ensure compliance with this specific part of the discharge process, hospital policy-makers may include a checklist for this item on the discharge summary template for their respective hospitals and they may institute incident reports for failure to comply with the policy.
- Teach ROM (range of motion) exercises. For elderly patients and those who were admitted to the hospital due to falls, mobility issues may still persist even after they leave the hospital. To prevent their conditions from worsening, nurses may teach some simple range of motion exercises to these patients. These exercises can often be done alone or with the help of a caretaker. This also helps ensure that the patient does not stay glued to a chair or bed at home and then develop bed sores—something that can be a cause of hospital readmission.
- Coordinate with social services and the local community health team. Elderly and marginalized patients may have a difficult time complying with a medication and rehabilitation regimen after they are discharged. To help them, hospital nurses and physicians may readily arrange for social services to assist these patients while they are still at the hospital. This way, they can receive continuity of care after they are discharged.
We hope you were able to learn more about hospital discharge forms from this article. Do check out the other posts on our website for information on a variety of topics.