FREE 5+ Discharge Summary Nursing Note Samples [ Progress, Patient, Home ]

A discharge summary is an important document to help keep the patient safe and in a stable and good condition when they are discharged from the hospital. It tells them the diagnosis of their health problem, the treatment they received, and the medications and ongoing treatment they need to take after being discharged. Physicians are responsible to give the instructions while nurses are the ones responsible to transcribe the details in the discharge summary note. Making a discharge summary is easy, as long as you already have the important details to input in the summary. Read the article to know how to make a discharge summary nursing note.

A discharge summary is an important document to help keep the patient safe and in a stable and good condition when they are discharged from the hospital. It tells them the diagnosis of their health problem, the treatment they received, and the medications and ongoing treatment they need to take after being discharged. Physicians are responsible to give the instructions while nurses are the ones responsible to transcribe the details in the discharge summary note. Making a discharge summary is easy, as long as you already have the important details to input in the summary. Read the article to know how to make a discharge summary nursing note.

5+ Discharge Summary Nursing Note Samples

1. Discharge Summary Residential Nursing Note

2. Discharge Summary Nursing Field Note

3. Discharge Summary Nursing Procedure Note

4. Discharge Summary Nursing Transfer Note

5. Discharge Summary Transitions Care Note

6. Discharge Summary Physician Note

 What is a Discharge Summary?

A discharge summary is a letter written by the physician who is assigned to take care of a patient admitted to the hospital and is going to be discharged soon. It contains important information about the patient’s hospital visit. The summary is printed in several copies for the patient’s copy, the physician, and the hospital for record-keeping.

Details to Include in a Discharge Summary Nursing Note

1. Patient Details

The first part of the summary note is the patient’s details. Important information must be included about the patient like personal information and emergency contacts.

2. Hospitalization Reasons

The next part of the summary is the description of the patient’s primary present condition and the patient’s initial diagnostic evaluation.

3. Findings

The next part is the findings or the diagnoses that the attending physician made during the patient’s stay in the hospital. When documenting the diagnoses, make sure the details are specific. If no diagnoses are being made, document the present complaint of the patient and explain that no cause was identified.

4. Procedures and Treatment

This part is where you include the information on how the patient was treated during their stay. The information must include:

• Management: Explain how the patient was managed during their hospital stay (include any long-term management, if it’s the case for the patient) and description of the events that occurred to the patient during their stay.
• Complications: Include details of any complications that happened
• Procedures: This part must include all medical procedures (such as operations, for example) that the patient underwent. Give a comprehensive explanation here such as the date of procedure, the procedure itself; such as the surgery process, any anesthesia agents being injected into the patient, etc.

5. Discharge Condition of the Patient

Document how the patient is doing and their health condition while on the way for their discharge.

6. Medical Instructions

The next part is the instructions from the physician to the patient and their family. The details here must include their discharge medication, activity and therapy orders, dietary instructions, medical follow-up, and treatment for chronic illnesses.

7. Physician’s signature

The summary must be concluded with the signature of the attending physician on the discharge summary.

FAQs

If you are in charge to transcribe all the doctor’s and nurse’s discharge notes, make sure you include every specific detail. Make sure that no important detail is forgotten. Always review the summary before sending it to the physician for review. To help you get started writing the discharge summary nursing note, download the free sample templates provided above to use as your guide.