Discharge note
The note that closes the admission: final diagnoses, the course of the stay and what changed.
About the discharge note
The discharge note closes the inpatient record: it is the internal summary of the stay, separate from the letter that goes back to the GP. Medication changes are flagged rather than buried in a list, so a reader can see at a glance what is new, what stopped and what is unchanged.
Day of discharge: final diagnoses, hospital course, pending results, discharge medications with changes flagged, follow-up and patient instructions.
The template, filled in.
The section headings below are the shape this template lays down. The content is a synthetic worked example, not a real patient, so you can see what a filled document looks like before you sign up.
Every template passes the clinical board before release. A template controls the shape of a document, nothing more: the impression and the plan are yours, and no document built from it is filed, sent or billed until you sign.
More in Notes and rounds
Your paperwork, in your shape.
Start the trial, bring a typical list, and the discharge note is shaped to your round before you sign your first one. See the full template set, or how the whole product works on the product page.
[email protected] · Australian data residency // always doctor-signed