Discharge note template
The day-of-discharge entry in the inpatient record.
- Status at discharge
- Clinical state, mobility, oral intake, continence.
- Final diagnoses
- Primary, then secondary.
- Hospital course summary
- The admission in a paragraph.
- Investigations pending
- Results outstanding at discharge.
- Discharge medications
- Route, frequency, duration; changes from admission flagged.
- Follow-up arrangements
- Specialist, GP, imaging and pathology.
- Patient instructions
- Red flags, activity restrictions, wound care.
Worked examples
Discharge note · medical admission Hartley, Pamela · 73F · Synthetic patient
Status at discharge Afebrile 48 h. Mobilising independently. Eating and drinking normally. Final diagnoses Community-acquired pneumonia, resolved. Type 2 diabetes, stable. Hospital course 4-day admission. IV benzylpenicillin and doxycycline, stepped down to PO amoxicillin on day 3. Afebrile from day 2. Investigations pending Sputum culture. Repeat CXR at 6 weeks to confirm resolution. Discharge medications Amoxicillin 1 g PO TDS for 3 more days, to complete 7 days (new). Metformin and perindopril unchanged. Follow-up GP review in 1 week. Respiratory clinic if symptoms persist beyond 6 weeks. Patient instructions Return if fever, worsening breathlessness or new chest pain. Finish the full antibiotic course.
Discharge note · surgical admission Kerr, Douglas · 68M · Synthetic patient
Status at discharge Day 4 post R TKR. Walking 40 m with a frame. Wound dry. Pain controlled on oral analgesia. Final diagnoses Osteoarthritis of the right knee, treated by total knee replacement. Hospital course Uncomplicated. Physiotherapy from day 1. Hb fell to 98, not transfused. Investigations pending FBC in 1 week. Discharge medications Enoxaparin 40 mg SC daily to complete 14 days (new). Paracetamol 1 g QID (new). Oxycodone 5 mg PRN, 10 tablets, stop by 2 weeks (new). Usual antihypertensives unchanged. Follow-up Wound check with the practice nurse at day 10 to 14. Rooms at 6 weeks. Outpatient physiotherapy twice weekly. Patient instructions Weight bear as tolerated. Return for calf pain, wound discharge, fever or shortness of breath.
