A discharge summary states the admission reason, hospital course, procedures performed, significant findings, discharge diagnoses, condition at discharge, medications, and follow-up instructions.
It is prepared at the conclusion of an inpatient stay.
Alternative Names:
Discharge Note, Hospital Discharge Summary
Why it Matters?
This is the highest-value single document in most hospitalization records because it condenses the entire admission and states the treating team's conclusions. Condition at discharge and follow-up instructions are particularly useful, since a patient discharged in stable condition with routine follow-up presents differently than the account given in litigation. It is also the fastest route to understanding a complex admission before reading the full chart.
Frequently Confused with
Related terms
Frequently asked questions
What does a discharge summary contain?
Why read it first?
