Discharge summary template, with a complete example
Used by: Hospitalists and residents at discharge; read by the primary care physician and the next facility.
The discharge summary is written for someone who was not there: the primary care physician, the skilled nursing facility, or the next admitting team. It needs the diagnosis, what was done, what changed, and exactly what to follow up.
The template, section by section
Diagnoses
Principal diagnosis and secondary diagnoses addressed during the stay.
- Principal diagnosis
- Secondary diagnoses
Hospital course
A problem-based summary of what happened and why.
- Course by problem
- Procedures
- Consultants
Discharge condition and data
Condition, exam, weight and key results at discharge.
- Condition and function
- Discharge weight and vitals
- Key results, including pending ones
Medications
The reconciled list, with what started, stopped and changed.
- New
- Changed
- Stopped
- Unchanged
Follow-up
Appointments, labs to recheck, and the specific questions for the next clinician.
- Appointments with dates
- Labs and when
- Pending results and who follows them
- Instructions and return precautions
Discharge summary example
A synthetic example written for an invented patient. It is not a real patient record or medical advice.
Principal diagnosis
Acute on chronic systolic heart failure, precipitated by interruption of home diuretic.
Secondary diagnoses
Acute kidney injury on CKD stage 3a, resolved. Type 2 diabetes. Hypertension.
Hospital course
1. Heart failure: admitted with volume overload and hypoxemia after 6 days without furosemide. Diuresed with IV furosemide, net negative 4.1 L, weight 88.4 kg to 84.6 kg. Oxygen weaned on day 2. Transitioned to oral furosemide 40 mg twice daily on day 3 with stable weight and renal function. Guideline-directed therapy continued.
2. AKI on CKD 3a: creatinine peaked at 1.5 (baseline 1.3) and was 1.3 at discharge.
3. Diabetes: metformin held for AKI, restarted at discharge. A1c 7.6%.
4. Medication access: the refill gap was due to a lapsed prescription; a 90-day supply was sent and the patient has it in hand.
Discharge condition
Stable, ambulating independently, SpO2 96% on room air, discharge weight 84.6 kg.
Medications
Changed: furosemide 40 mg twice daily (was 40 mg daily). Unchanged: carvedilol 12.5 mg twice daily, sacubitril-valsartan 49-51 mg twice daily, metformin 1000 mg twice daily.
Follow-up
Primary care within 7 days. Cardiology clinic in 2 weeks. BMP in 1 week to check potassium and creatinine on the higher diuretic dose. Daily weights at home; call for a gain of more than 1 kg in a day or 2 kg in a week.
Pending at discharge: none.
Tips from practice
- List medication changes explicitly; it is the section most often used and most often wrong.
- Name pending results and who will follow them.
- Give the follow-up clinician a specific question, not just an appointment.
Let the note write itself in this format
Scribeable writes the note from the visit in the template you choose and suggests the codes, and each sentence drawn from the visit links back to where it came from. You review and sign.
14-day Pro trial, no credit card required. Everything in Pro, including Rounding, for up to 150 notes. To keep Pro after day 14, subscribe for $79/month plus applicable tax. If you don't, nothing is charged and your account becomes read-only, with every note kept.
Questions
- What must a discharge summary include?
- At minimum: diagnoses, a summary of the hospital course, condition at discharge, reconciled medications with changes, follow-up appointments and tests, and pending results.
- Can an AI scribe write a discharge summary?
- Yes. Scribeable writes the discharge summary from the notes of the stay, and each sentence drawn from them links to its source, so you check the course rather than rebuild it. Reconcile medications against your EHR before signing.
Reviewed 2026-11-08.