The discharge summary is the handoff that the next clinician (and the patient) actually relies on: why they were admitted, what happened, what changed, and what to do next. This skill structures the stay into a complete, scannable summary so nothing critical — a new medication, a pending result, a follow-up — falls through the gap.
Clinical-safety note: this is a documentation-formatting aid, not medical advice. It organises information a qualified clinician provides; the treating clinician must review and verify every detail (especially the medication list and follow-up) before it is finalised. Do not invent diagnoses, medications, doses, or results.
Working from a brief
Given the admission notes and course, produce the full summary anyway — organise what's provided into every standard section. Where a section's detail wasn't given, mark it clearly (e.g. "Pending results: none reported") rather than inventing it. Never fabricate medications, doses, or diagnoses.
Required Inputs
Ask for these only if they aren't already provided (else mark as not documented):
- Admission — reason for admission, date, and presenting problem.
- Hospital course — what happened during the stay: diagnoses, key events, procedures, consults, results.
- Discharge medications — the reconciled med list (new, changed, stopped, continued).
- Discharge status & disposition — condition at discharge and where they're going (home, facility).
- Follow-up — appointments, pending results, and return/escalation precautions.
Output Format
Discharge Summary
- Patient & dates — identifiers as provided; admission and discharge dates.
- Admission diagnosis / reason for admission.
- Discharge diagnoses — principal and secondary.
- Hospital course — a concise narrative of the stay: presentation → workup → treatment → response, by problem.
- Procedures / significant events — with dates.
- Discharge medications — reconciled list, flagging new / changed / discontinued explicitly.
- Condition at discharge & disposition.
- Follow-up plan — appointments (who/when), pending results to chase, and clear return precautions (when to seek care).
- Patient instructions — in plain language for the patient/carer.
Close with fields not documented and a clinician-review reminder.
Quality Checks
- Medication reconciliation is explicit — new / changed / stopped / continued are distinguished
- Follow-up names who, when, and any pending results to chase — nothing left dangling
- Clear return/escalation precautions are included for the patient
- The hospital course is organised by problem, not a raw chronological dump
- No diagnosis, medication, dose, or result is invented — gaps are marked
- A patient-facing plain-language instruction set is included alongside the clinical summary
Anti-Patterns
- Do not invent medications, doses, diagnoses, or results to complete a section
- Do not present this as medical advice — it formats clinician-provided information for handoff
- Do not leave the medication list ambiguous about what changed during the stay
- Do not omit pending results or follow-up ownership — that's where handoffs fail
- Do not write patient instructions in clinical jargon the patient can't act on
Based On
Clinical handoff/documentation practice — structured discharge summaries with medication reconciliation, explicit follow-up, and return precautions.