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Registered Nurse
25-30 minutes

Standardized Hospital Discharge Summary Narrative Template

The Generic Hospital Discharge Summary Narrative Format is an all-encompassing template designed for healthcare professionals to meticulously document a patient's hospital stay and discharge information. This indispensable tool ensures seamless continuity of care by incorporating vital details such as diagnoses, treatment regimens, medication plans, and follow-up instructions. It is especially beneficial for nurses who require a detailed and organized discharge summary to promote effective communication with patients and other healthcare providers. This template is optimized for use with s10.ai, an AI medical scribe, to streamline documentation and elevate patient care outcomes.

3,778 uses
4.7/5.0
J
Jordan Patel
Template Structure

Organized sections for comprehensive clinical documentation

The patient, [patient name], was born on [patient date of birth] and is identified by medical record number [patient medical record number]. For any inquiries, the patient can be reached at [patient contact information].
The patient was admitted on [admission date] and discharged on [discharge date] at [medical hospital name]. The attending physician overseeing the case was [attending physician name]. The care was further supported by consulting physicians, including [consulting physicians names], who provided additional expertise and recommendations throughout the patient's stay.
During the hospital stay, the primary diagnosis was identified as [primary medical diagnosis]. In addition, the patient presented with secondary diagnoses of [secondary medical diagnoses], which contributed to the complexity of their care. The patient also had comorbidities, including [medical comorbidities], which necessitated a comprehensive management approach.
Throughout the hospital stay, the patient experienced a series of events that shaped their treatment. Key events included [mention any significant occurrences, such as tests, changes in condition, or responses to medical treatment]. The patient's progress was monitored closely, with observations indicating [describe any improvements or setbacks]. However, complications arose during the stay, including [detail any complications that occurred, such as infections, adverse reactions, or unexpected changes in condition].
During this period, the patient underwent several procedures and treatments, including [list of procedures and treatments provided]. These interventions were critical in addressing the patient's needs and advancing their recovery. Notably, changes were made to the patient's medication regimen, with specific alterations including [details of any medication changes, such as dosage adjustments, new medications introduced, or medications discontinued].
Upon discharge, the patient was advised to continue the following medications: [comprehensive list of medications the patient is to continue post-discharge]. This medication plan is essential for managing the patient’s ongoing health needs. It is also important to note that the patient has allergies to [list of allergies], which must be considered in future treatments. Additional special considerations included [any other special considerations that are relevant to the patient's care or discharge].
For follow-up, the patient is scheduled for [details of follow-up appointments, tests, and any pending results], which will ensure continued monitoring and support in their recovery process. The patient received specific advice and self-care instructions, which included [specific advice and self-care instructions provided to the patient], empowering them to manage their health post-discharge effectively.
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines and paragraphs as needed to capture all the relevant information from the transcript.)
Sample Clinical Note

Example of completed documentation using this template

The patient, John Doe, was born on 15 March 1975 and is identified by medical record number 123456789. For any inquiries, the patient can be reached at 555-123-4567.
The patient was admitted on 25 February 2024 and discharged on 1 March 2024 at General Medical Center. The attending physician overseeing the case was Dr. Thomas Kelly. The care was further supported by consulting physicians, including Dr. Sarah Lee and Dr. Michael Brown, who provided additional expertise and recommendations throughout the patient's stay.
During the hospital stay, the primary diagnosis was identified as acute myocardial infarction. In addition, the patient presented with secondary diagnoses of hypertension and type 2 diabetes, which contributed to the complexity of their care. The patient also had comorbidities, including chronic kidney disease, which necessitated a comprehensive management approach.
Throughout the hospital stay, the patient experienced a series of events that shaped their treatment. Key events included an emergency coronary angioplasty, stabilization of blood pressure, and management of blood glucose levels. The patient's progress was monitored closely, with observations indicating gradual improvement in cardiac function. However, complications arose during the stay, including a mild allergic reaction to a medication, which was promptly addressed.
During this period, the patient underwent several procedures and treatments, including coronary angioplasty, echocardiogram, and insulin therapy. These interventions were critical in addressing the patient's needs and advancing their recovery. Notably, changes were made to the patient's medication regimen, with specific alterations including the introduction of a beta-blocker and adjustment of insulin dosage.
Upon discharge, the patient was advised to continue the following medications: aspirin, metoprolol, lisinopril, and insulin. This medication plan is essential for managing the patient’s ongoing health needs. It is also important to note that the patient has allergies to penicillin, which must be considered in future treatments. Additional special considerations included dietary modifications to manage diabetes and hypertension.
For follow-up, the patient is scheduled for a cardiology appointment on 15 April 2025 and a renal function test on 20 April 2025, which will ensure continued monitoring and support in their recovery process. The patient received specific advice and self-care instructions, which included maintaining a low-sodium diet, regular blood glucose monitoring, and engaging in moderate physical activity, empowering them to manage their health post-discharge effectively.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline patient documentation, ensuring that healthcare professionals can efficiently capture and manage critical patient information. By incorporating high-search healthcare and clinical keywords, this template enhances the accuracy and accessibility of patient records. It includes detailed sections for patient demographics, admission and discharge details, primary and secondary diagnoses, comorbidities, and key events during the hospital stay. The template also covers procedures, treatments, medication regimens, allergies, and special considerations, providing a holistic view of the patient's care journey. Additionally, it outlines follow-up appointments and self-care instructions, facilitating seamless continuity of care. Clinicians are encouraged to adopt this template to improve documentation efficiency, enhance patient care, and support better clinical outcomes.
Frequently Asked Questions

Common questions about this template and its usage

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