11/13/24, 7\:41 PM Guide | Writing a discharge letter

Writing a discharge letter

Table of contents

Introduction

Discharging patients from a hospital is a complex task. An essential part of this process is the documentation of a discharge
summary. A discharge summary is a clinical report prepared by a health professional at the conclusion of a hospital stay or
series of treatments. It is often the primary mode of communication between the hospital care team and aftercare providers. It
is considered a legal document and it has the potential to jeopardize the patient’s care if errors are made. Delays in the
completion of the discharge summary are associated with higher rates of readmission, highlighting the importance of
successful transmission of this document in a timely fashion.
This guide will help you to understand what’s necessary to include and give you a structure to e
summaries. It gives a detailed description of each section that may be included in a typical discharge summary. Each section
illustrates key pieces of information that should be included and aims to explain the rationale behind each part of the
document.
In practice, each summary is adapted to the clinical context. As such, not all information included in this guide is relevant and
needs to be mentioned in each discharge summary. In addition, di
should always follow your hospital’s or medical school's guidelines for documentation.

Demographics

Patient details

Important information to include regarding the patient includes\:
Patient name\: full name of the patient (also the patient's preferred name if relevant)
Date of birth
Unique identi
Patient address\: the usual place of residence of the patient
Patient telephone number
Patient sex\: sex at birth (this determines how the individual will be treated clinically)
Gender\: the gender the patient identi
Ethnicity\: ethnicity as speci
Next of kin/emergency contact\: full name, relationship to the patient and contact details

GP details

This section should be completed with the details of the General Practitioner with whom the patient is registered\:
GP name\: the patient's usual GP
GP practice details\: name, address, email, telephone number and fax of the patient’s registered GP practice
GP practice identi

Hospital details

This section should encompass the salient aspects of the patient’s discharge\:
Discharging consultant\: the consultant responsible for the patient at the time of discharge
Discharging specialty/department\: the specialty/department responsible for the patient at the time of discharge
Date and time of admission and discharge
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Discharge destination\: destination of the patient on discharge from hospital (e.g. home, residential care home)

Clinical details

Presentation

History and examination
Include a focused summary of the patient's presenting symptoms and signs\:
" M r s S m i t h p r e s e n t e d t o A & E w i t h w o r s e n i n g s h o r t n e s s o f b r e a t h a n d a n k l e s w e l l i n g. O n a r r i v a l , s h e w a s t a c h y p n o e i c a n d
h y p o x i c ( o x y g e n s a t u r a t i o n 8 2 % o n a i r ) . C l i n i c a l e x a m i n a t i o n r e v e a l e d r e d u c e d b r e a t h s o u n d s a n d d u l l n e s s t o p e r c u s s i o n i n
b o t h l u n g b a s e s . T h e r e w a s a l s o a s i g n i
"
Investigations
Include salient investigations performed during the patient's admission\:
" B l o o d t e s t s r e v e a l e d a r a i s e d B N P . A n E C G s h o w e d e v i d e n c e o f l e f t-v e n t r i c u l a r h y p e r t r o p h y a n d e c h o c a r d i o g r a p h y r e v e a l e d
g r o s s l y i m p a i r e d v e n t r i c u l a r f u n c t i o n ( e j e c t i o n f r a c t i o n 3 5 % ) . A c h e s t X -r a y d e m o n s t r a t e d b i l a t e r a l p l e u r a l e
e v i d e n c e o f u p p e r l o b e d i v e r s i o n .
"
Include any investigations that are still pending\:
" A r e n a l t r a c t u l t r a s o u n d h a s b e e n r e q u e s t e d a n d w i l l b e p e r f o r m e d i n t h e n e x t 2 w e e k s . W e w i l l w r i t e t o y o u w i t h t h e r e s u l t s .
"
Diagnoses
This section should include the diagnosis or diagnoses that were made during the patient's stay in hospital\:
" M r s S m i t h w a s r e v i e w e d b y t h e C a r d i o l o gy t e a m w h o c o n
"
If no diagnosis was con
" N o c l e a r c a u s e w a s i d e n t i
"
Be as speci
details include\:
Diabetes\: type 1, type 2, steroid-induced, gestational
Myocardial infarction\: NSTEMI, STEMI
Pneumonia\: bacterial, viral, aspiration pneumonia
Septicaemia\: causative organism and source (e.g. E.Coli urosepsis)
Gastroenteritis\: viral, bacterial
Management
initiated\:
Explain how the patient was managed during their hospital stay and include any long term management that has been
" M r s S m i t h r e q u i r e d o x y g e n a n d i n t r a v e n o u s d i u r e t i c t h e r a p y f o r t h e
o x y g e n a n d c o m m e n c e d o n r e g u l a r o r a l f u r o s e m i d e ( 4 0 m g O D ) w h i c h i s t o b e c o n t i n u e d a f t e r d i s c h a r g e . A t d i s c h a r ge , M r s
S m i t h' s s y m p t o m s w e r e m u c h i m p r o v e d a n d s h e w a s a b l e t o m o b i l i s e i n d e p e n d e n t l y w i t h o n l y m i l d s h o r t n e s s o f b r e a t h o n
e x e r t i o n .
"
Complications
Document any complications that occurred during the patient's hospital stay\:
" M r s S m i t h d e v e l o p e d a s t a g e 2 a c u t e k i d n e y i n j u r y a f t e r i n i t i a t i o n o f d i u r e t i c t h e r a p y , h o w e v e r , t h i s r e s o l v e d w i t h d o s e
t i t r a t i o n a n d c a r e f u l _μ_m o l / L .
"
Procedures
This section must include all operations or procedures that the patient underwent\:
Date of procedure(s)\: the date the procedure(s) was/were performed
Procedure\: the procedure performed (e.g. laparoscopic appendectomy)
Complications related to the procedure\: details of any intra-operative complications encountered during the procedure,
arising during the patient’s stay in the recovery unit or directly attributable to the procedure (e.g. injury to surrounding
structures, secondary wound infections, etc)
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Speci
di

Future management

Include details of the current plan to manage the patient and their condition(s) after discharge from hospital\:
Treatments (e.g. medication, surgery, etc)
Hospital follow up
Referrals made by the hospital (e.g. referral to chronic pain team)
Example\: " W e h a v e d i s c h a r g e d M r s S m i t h o n r e gu l a r o r a l F u r o s e m i d e ( 4 0 m g O D ) a n d w e h a v e r e q u e s t e d a n o u t p a t i e n t
u l t r a s o u n d o f h e r r e n a l t r a c t w h i c h w i l l b e p e r f o r m e d i n t h e n e x t f e w w e e k s . W e w i l l r e v i e w M r s S m i t h i n t h e C a r d i o l o gy
O u t p a t i e n t C l i n i c i n 6 w e e k s t i m e . A f t e r r e v i e w f r o m o u r s o c i a l w o r k e r a n d o c c u p a t i o n a l t h e r a p i s t , w e h a v e a r r a n ge d a o n c e-
d a i l y c a r e p a c k a g e t o a s s i s t M r s S m i t h w i t h h e r a c t i v i t i e s o f d a i l y l i v i n g."
Clearly document any actions you would like the patient's GP to perform after discharge\:
" C o u l d y o u p l e a s e a r r a n g e f o r M r s S m i t h' s U & E s t o b e a s s e s s e d i n 2 w e e k s t i m e , t o e n s u r e h e r c r e a t i n i n e a n d e l e c t r o l y t e s
r e m a i n s t a b l e o n h e r n e w d i u r e t i c r e g i m e . S h o u l d y o u h a v e a n y q u e s t i o n s o r c o n c e r n s i n t h e m e a n t i m e , p l e a s e d o n' t h e s i t a t e
t o c o n t a c t o u r t e a m .
"

Medications

Medication changes

Summarise any changes to the patient's regular medication and provide an explanation as to why the changes were made if
possible\:
" A m l o d i p i n e I N C R E A S E D t o 1 0 m g o n c e d a i l y t o i m p r o v e b l o o d p r e s s u r e c o n t r o l .
"
" C i t a l o p r a m 2 0 m g o n c e d a i l y C O M M E N C E D d u e t o l o w m o o d .
"
" F u r o s e m i d e 4 0 m g o n c e d a i l y S T O P P E D d u e t o a c u t e k i d n e y i n j u r y .
"

Medications to take home

You should include a list of all medications that the patient is currently taking, including\:
Regular medications
As required (PRN) medications
For each medication, you should include details regarding the following\:
Name\: usually, generic drug names are preferred, but in some cases using the speci
epilepsy medication)
Form\: capsule, drops, tablet, lotion, etc
Route\: oral, inhaled, topic, intravenous, etc
Frequency\: once daily, twice daily, as required, etc
Duration\: x days, long-term, etc
Indication\: e.g. congestive heart failure
Additional instructions\: review date, monitoring requirements, etc

Allergies and adverse reactions

This section should outline any allergies or adverse reactions that the patient experienced. It should be as speci
possible and include the following\:
Causative agent\: the agent (food, drug or substances) that caused an allergic reaction or adverse reaction
Description of the reaction\: this may include the manifestation (e.g. rash), type of reaction (allergic, adverse, intolerance)
and the severity of the reaction
Date
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Information for the patient

Most discharge letters include a section that summarises the key information of the patient's hospital stay in patient-friendly
language, including investigation results, diagnoses, management and follow up. This is often given to the patient at
discharge or posted out to the patient's home.
" Y o u w e r e a d m i t t e d t o h o s p i t a l b e c a u s e o f w o r s e n i n g s h o r t n e s s o f b r e a t h a n d s w e l l i n g o f y o u r a n k l e s . W e p e r f o r m e d a n u m b e r
o f t e s t s w h i c h r e v e a l e d t h a t y o u r h e a r t w a s n' t p u m p i n g a s e
a w a t e r t a b l e t c a l l e d F u r o s e m i d e , w h i c h s h o u l d h e l p t o p r e v e n t
c o n t i n u e t o t a k e t h e F u r o s e m i d e t a b l e t a s p r e s c r i b e d , h o w e v e r , i f y o u b e c o m e u n w e l l , y o u s h o u l d s e e y o u r G P a s t h i s t a b l e t c a n
p o t e n t i a l l y d a m a g e y o u r k i d n e y s i f y o u b e c o m e d e h y d r a t e d . W e p l a n t o r e v i e w y o u i n 6 w e e k s t i m e , i n t h e C a r d i o l o gy
O u t p a t i e n t C l i n i c a n d w e w i l l s e n d y o u r a p p o i n t m e n t d e t a i l s o u t i n t h e p o s t . W e h a v e a l s o a s k e d y o u r G P t o t a k e s o m e b l o o d
t e s t s t o c h e c k y o u r k i d n e y f u n c t i o n i n a r o u n d 2 w e e k s t i m e . I n t h e m e a n t i m e , s h o u l d y o u h a v e a n y c o n c e r n s o r q u e s t i o n s , y o u
s h o u l d s e e y o u r G P .
"

Person completing the record

This section includes personal information about the healthcare provider completing the discharge summary\:
Name
Designation or role
Grade
Specialty
Date completed

Other sections that may be included

Assessment scales

This section identi
scales commonly used include\:
New York Heart Association (NYHA) Functional Classi
Cognitive function (e.g. MMSE)
Mood assessment scales
Malnutrition Universal Screening Tool (MUST)

Social context

Home circumstances\:
Who the patient lives with (e.g. lives alone, lives with a partner, lives with family)
Details of the patient's residence (e.g. house with stairs, bungalow,
Occupational history\:
Current and/or previous relevant occupation(s) of the patient

Special requirements

Document if the patient has any special requirements\:
Transport arrangements (e.g. ambulance with oxygen)
Language (e.g. preferred language, need for an interpreter)
Advocate requirements

Participation in research

This is to clearly identify patients who are involved in a clinical trial.
This may include\:
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Whether participation in a trial has been o
Name of the trial
Drug/Intervention tested
Enrolment date
Duration of treatment and follow up
A contact number for adverse events or queries

Legal information

This section describes the care of the patient from a legal perspective. Some examples of the types of information it may
include are shown below.
Consent for treatment record\:
Whether consent has been obtained for the treatment
Mental capacity assessment\:
Whether an assessment of the mental capacity of the (adult) patient has been undertaken, if so, who carried it out, when it
was carried out and the outcome of the assessment
Advance decisions about treatment\:
Whether there are written documents, completed and signed when a person is legally competent, that explains a person’s
medical wishes in advance, allowing someone else to make treatment decisions on his/her behalf late in the disease
process
Location of these documents
A copy of the document itself
Lasting or enduring power of attorney or similar\:
Record of individual involved in healthcare decision on behalf of the patient if the patient lacks capacity
Organ and tissue donation\:
A record of whether a patient has consented for organ or tissue donation.
Consent relating to a child\:
Consideration of age and competency
Record of the person with parental responsibility, or appointed guardian where a child lacks competency
Consent to information sharing\:
Record of consent to information sharing, including any restrictions on sharing information with others (e.g. family members,
other healthcare professionals)
Use of identi
Safeguarding issues\:
Any legal matters relating to the safeguarding of a vulnerable child or adult (e.g. child protection plan, a child in need plan,
protection of a vulnerable adult)

Safety alerts

This section illustrates if the patient poses a risk to themselves, for example, suicide, overdose, self-harm, self-neglect. Also
include if the patient is a risk to others, including professionals or any third party.

Patient and carer concerns

This section should include a description of any concerns of the patient and/or carer.

References

1. Health and Social Care Information Centre, Academy of Medical Royal Colleges. Standards for the clinical structure and content
of patient records [Internet]. London\: Health and Social Care Information Centre, Academy of Medical Royal Colleges; 2013 p. 37
- 44. Available from\: [LINK]
https\://app.geekymedics.com/osce-guides/documentation/writing-a-discharge-letter/ 5/611/13/24, 7\:41 PM Guide | Writing a discharge letter
2. UpToDate [Internet]. Uptodate.com. 2019 [cited 28 January 2019]. Available from\: [LINK]
Source\: geekymedics.com
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