Clinical template
Discharge Summary Template with Examples
A discharge summary is the hospital-to-GP handoff. The family physician was not on the ward. They need diagnoses, what changed, the medication list that left with the patient, tests still pending, and who owns the next step. Use the blank below, then two fictional Canadian cases — one medical, one surgical.
Blank discharge summary
Copy this into the hospital dictation system, a Word letter, or a Scribeberry custom template. Fill pending results even when the box is empty — write 'none' so the GP does not have to guess.
Discharge summary
Patient: [name, DOB, PHN/MRN] Admitting service / MRP: Admission date: Discharge date: Destination: home / rehab / LTC / other hospital Copy to: [GP name, other consultants] Most responsible diagnosis: Other diagnoses (active): Procedures (date, operator): Allergies / adverse reactions: Hospital course (by problem, not by day): Complications / ICU / code events: Key investigations (result + date): Pending results (test, date drawn, who follows, how they are notified): Medication reconciliation at discharge Home meds continued unchanged: Home meds dose/route changed (was → now, reason): Home meds stopped (reason): New meds started (dose, duration or ongoing, indication): High-alert (anticoagulant, insulin, opioid, immunosuppressant): Community pharmacy / blister pack / compliance packaging: Follow-up (who, when, booked vs patient to book, what to bring): Home supports / homecare / equipment: Patient / SDM instructions and safety-net: Goals of care / code status if discussed this admission:
Fictional patients
Every example on this page uses made-up names and findings. They are teaching material. They are not a substitute for your hospital's discharge policy, pharmacy med-rec process, or college standards. Review every generated summary before it is signed and sent.
What the GP actually needs
The receiving clinician opens this letter weeks later, often without the inpatient chart. A day-by-day ward diary is unreadable. Write by problem: what the patient came in with, what you found, what you did, what is left hanging. If the family doctor has to phone Health Records for a pending culture, the summary failed.
| Section | What belongs here | What does not |
|---|---|---|
| Diagnoses | Most responsible diagnosis, plus active comorbidities that changed management | Every historical ICD code from the coding abstract |
| Hospital course | Problem-oriented narrative, complications, decisions that affect outpatient care | A transcript of each daily progress note |
| Med rec | Every change from the home list, with dose and reason; high-alert drugs named | 'See MAR' or a photocopy of inpatient orders with no home comparison |
| Pending results | Test, draw date, who owns the result, how the GP is told | 'Labs pending' with no owner |
| Follow-up | Named clinician, timeframe, booked vs not, what the visit is for | 'Follow up with GP' and nothing else |
Accreditation programs in Canada treat medication reconciliation at discharge as a required practice, not a courtesy. The discharge list has to be compared with the best possible medication history from admission, not only with last night's MAR. If a home antihypertensive was held for hypotension and never restarted, say so.
Medication reconciliation
Four columns, not one list: continued, changed, stopped, new. Include OTC, inhalers, patches, insulin, and devices (CPAP, glucometer strips) if they were part of inpatient care. Name the community pharmacy if blister packing or a compliance pack needs a new fill. For anticoagulants, insulin, and opioids, write the indication and the planned stop or INR plan in the same block as the dose.
- Stopped drugs need a reason the GP can act on ('AKI, Cr peaked 186, hold ramipril pending eGFR') rather than 'held'.
- New short courses need a stop date (antibiotics, steroids, VTE prophylaxis).
- If the patient leaves on a new DOAC, state whether the home warfarin was stopped and whether bridging occurred.
- Allergy updates made this admission belong in the summary, not only in the inpatient banner.
Pending results and follow-up
Pathology, cultures finalized after discharge, send-out serology, and delayed imaging reports are how patients fall through. Each pending item needs an owner: MRP, discharging resident, GP, or specialist clinic. 'GP to follow' is only honest if the GP is copied, knows the test exists, and has a way to see the result in the provincial repository or a faxed report.
Follow-up appointments that are booked go in with date, clinic, and what to bring (INR, wound check, staples). Follow-up that is not booked goes in as an instruction with a timeframe. Homecare, oxygen, and mobility equipment belong here so the clinic visit is not the first time anyone asks whether the walker arrived.
Example 1 — medicine, COPD and pneumonia
Internal medicine, community hospital
71-year-old man, Winnipeg. 6-day admission. Discharged home. Fictional.
Patient: Harpreet S., DOB 1955-03-12, PHN on file Service: General internal medicine (Dr. K. Novak). Admitted 2026-08-20. Discharged 2026-08-26 home with daughter. Copy to: Dr. L. Banerjee (GP), respirology (no clinic booked). Most responsible diagnosis: Acute exacerbation of COPD secondary to community-acquired pneumonia (right lower lobe). Other: COPD GOLD 3, former smoker; T2DM; hypertension; CKD stage 3a (baseline Cr ~110). Procedures: none. Allergies: NKDA. Hospital course Presented with 4 days of productive cough, fever, and increased dyspnea on home 2 L O2 PRN. CXR RLL consolidation. Treated with ceftriaxone + azithromycin, then stepped down to amoxicillin-clavulanate. Prednisone 50 mg daily x 5 days completed in hospital. Two days of NIV in the first 48 h; no ICU transfer. Glucose ran 12–16 on steroids; metformin held, insulin sliding scale, metformin restarted day 4. Cr rose to 148 then settled to 118. PT/OT: stairs with rail, 2WW for community distances. Key investigations CXR 20 Aug: RLL consolidation. Repeat 25 Aug: improving. Sputum culture 20 Aug: mixed oral flora (final). Blood cultures NGTD. A1c 21 Aug: 7.6%. eGFR 52 on discharge. Pending results Legionella/pneumococcal urine antigens drawn 20 Aug — not resulted at dictation. MRP (Dr. Novak) will review; GP copied on this summary. No other pending. Medication reconciliation Continued: tiotropium 18 mcg inhaled daily; salbutamol 2 puffs QID PRN; metformin 1000 mg BID; atorvastatin 40 mg daily; amlodipine 5 mg daily. Changed: ramipril 10 mg daily → hold until GP reviews eGFR (AKI this admission, Cr now near baseline). Stopped: none else. New: amoxicillin-clavulanate 875/125 mg PO BID, complete 3 further days (stop 29 Aug). Prednisone completed. No new inhaler. High-alert: none new. Home insulin not used as outpatient. Follow-up GP in 7–10 days: restart vs stop ramipril, post-steroid glucose, whether CXR needs a 6-week film given smoking history (shared decision). Patient to book. Respirology not required this admission; GP may refer if exacerbations continue. Homecare: none. Oxygen: continue 2 L PRN as at home; no new LTOT assessment this stay. Safety-net: return to ED for fever, chest pain, or inability to speak full sentences. Daughter has the med list.
Example 2 — surgical, laparoscopic cholecystectomy
General surgery, overnight stay
54-year-old woman, Halifax. Admitted from ED with acute cholecystitis. Fictional.
Patient: Elena R., DOB 1972-06-04, PHN on file Service: General surgery (Dr. P. Cormier). Admitted 2026-08-24. Discharged 2026-08-26 home. Copy to: Dr. M. LeBlanc (GP). Most responsible diagnosis: Acute calculous cholecystitis. Other: obesity (BMI 34); no prior abdominal surgery. Procedures: laparoscopic cholecystectomy 25 Aug 2026 (Dr. Cormier); intraoperative cholangiogram normal; no drain. Allergies: penicillin — rash (not anaphylaxis). Hospital course ED presentation with RUQ pain 18 h, fever 38.2, Murphy positive, WBC 14.2, ultrasound stones and wall thickening, no CBD dilation. NPO, IV fluids, cefazolin (penicillin allergy is rash only; no beta-lactam issue this stay). Laparoscopy uneventful; gallbladder inflamed, no perforation. Diet advanced POD 0 evening. Pain controlled on oral agents. Voided. Mobilizing independently. Key investigations US 24 Aug as above. CBC POD 1: WBC 9.1. LFTs pre-op: ALT 42, ALP 98, bili 14; not repeated. Pending results Gallbladder pathology — specimen 25 Aug. Report to Dr. Cormier; office will call patient if unexpected. GP copied. No bloodwork pending. Medication reconciliation Continued: none (no standing home meds). New: hydromorphone 1 mg PO q4h PRN x 3 days then stop (dispense 12 tabs, no refills). Naproxen 375 mg PO BID with food x 5 days if no GI bleed history. Acetaminophen 1 g PO q6h x 5 days. Ondansetron 4 mg PO q8h PRN x 3 days. Stopped: IV cefazolin at discharge. No oral antibiotic (uncomplicated lap chole). High-alert: opioid — short course, bowel care (sennosides 17.2 mg qhs PRN), no driving while taking hydromorphone. Follow-up Surgery clinic 2–3 weeks, booked 2026-09-14 09:30, bring pathology if mailed. GP PRN; no routine bloodwork. Wound: three 5-mm sites, skin glue; shower tomorrow; no baths 1 week. Activity: no heavy lifting >10 kg x 2 weeks. Safety-net: ED for fever, increasing jaundice, persistent vomiting, or wound redness spreading.
Mistakes that leave the GP stranded
- No medication list, or an inpatient MAR pasted without comparing to home drugs.
- Pending pathology or cultures with no named owner.
- Follow-up written as 'as needed' after a new diagnosis that needs a timed visit.
- Hospital course that lists every vital sign from day 1 and never states the discharge diagnosis.
- Wrong GP on the copy list, or no copy at all when the patient has a family physician on the ADT screen.
- Anticoagulant or insulin changes buried in the narrative instead of the med-rec block.
CMPA files on discharge often turn on what was communicated, not what was intended. If the summary is generated from the last progress note, read it as if you were the outpatient doctor. Then sign.
Draft the discharge summary from the stay
Scribeberry can draft a problem-oriented discharge letter from dictation or the encounter audio, including med rec and follow-up headings in your template. Edit, then Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What should a hospital discharge summary include?
Diagnoses, procedures, a problem-oriented hospital course, allergies, a full medication reconciliation (continued, changed, stopped, new), pending results with an owner, follow-up that is specific, and copies to the GP and relevant consultants. Destination and homecare belong in the same letter.
Who is responsible for pending results after discharge?
Name an owner in the summary. That may be the MRP, a discharging resident under a service policy, a specialist clinic, or the GP if they are copied and can see the result. 'Pending' with no owner is how cultures and pathology go unread.
Is a discharge summary the same as a transfer note?
No. A transfer note (ward to ICU, or hospital to hospital) is written for clinicians who will keep treating the patient in the next hours. A discharge summary is written for the community clinician and the patient. Both need med rec; only the discharge letter has to stand alone weeks later.
Can Scribeberry generate a discharge summary?
Yes. Use a discharge template (or your hospital headings), dictate or record, and generate. You review medication changes and pending results before the letter is signed and sent. Custom templates keep your service's order of sections.
Templates
