Patient Discharge Process: Discharge Summary

Instructor: Adrianne Baron

Adrianne has a master's degree in cancer biology and has taught high school and college biology.

In this lesson, we're going to break down the various parts that need to be included in a patient discharge summary. We'll also cover a few examples for each part of the discharge summary.

Patient Discharge

A patient, Will, has just been rushed into the emergency department where you work. As a nurse, you are a part of the healthcare team that is treating Will. Even though Will just arrived to the hospital, the entire healthcare team is working on Will with one goal in mind, which is to get him better and facilitate the release from the hospital known as patient discharge.

Once Will's immediate life-threatening needs are met, discharge planning starts. Discharge planning is the plan of action to address the needs of the patient in the hospital setting and after discharge.

It's a week later and the discharge plan for Will has been a success. The healthcare team is ready to discharge Will from the hospital today, and the process is coming to a close. Everything that needs to be done to discharge Will has happened except the last step. The last step in the patient discharge process.

Discharge Summary

The last step when discharging a patient from the hospital is to write a discharge summary. As the name suggests, it is a summary of the entire hospitalization from arrival to discharge. There are several parts that need to be included in the discharge summary.

The reason for coming to the hospital is the first part of the discharge summary
Picture of emergency sign on the hospital

Document the Chief Complaint

The first part of the discharge summary is the reason why the patient came to the hospital. This is often referred to as the chief complaint. This might include anything from car accident injuries, heart palpitations, or labor. Will is a guy, so we know he wasn't in labor. He was, however, in a car accident, which caused his chief complaint to be severe pain in his neck and arm. The chief complaint will differ from one patient to the next, and there may be more than one reason why the patient ended up being hospitalized.

Document the Diagnosis

Secondly, you need to document the diagnosis and/or other significant findings that came out of the hospital stay. The diagnosis is the condition or disease that the physician determines is causing the signs and symptoms the patient is experiencing. In Will's case you document that he has a broken arm and a fractured neck. Other significant findings are usually additional diagnoses that may or may not be related to what the patient came in complaining about. An example could be finding that Will has high blood sugar, which clearly didn't happen due to the car accident.

Procedures and treatments should be summarized
Picture of surgery treatment

Summarize Procedures and Treatments

Next, you should summarize any procedures and/or treatments provided during the hospital stay. This section of the discharge summary should tell how and when procedures and treatments were done as well as the outcome. Examples of information that may appear in this part of the summary for Will are pain medications, IV administration, surgeries, and blood transfusions.

All details of the patient
Icon of a patient with a broken arm

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