Table of contents
What is a discharge summary?
A discharge summary is the structured handoff document that transfers clinical responsibility from the hospital team to the next-care provider — usually the PCP — at the end of an inpatient stay.
It exists at the intersection of three audiences: clinicians (who need to continue care), patients (who need to know what to do at home), and reviewers (billing, quality, malpractice). A good discharge summary is dense for clinicians, plain for patients, and complete for reviewers — usually as a single document with sections that read at different levels.
Required components
CMS Conditions of Participation §482.43 specifies these. Hospitals add their own elements (e.g., specific quality measures).
Admission diagnosis
The reason for admission, in clinical terms.
Hospital course
Chronological narrative of what happened — events, treatments, complications, response.
Discharge diagnosis
Final diagnoses, ranked by clinical importance, with associated ICD-10 codes for billing.
Procedures performed
All operative and bedside procedures with dates and CPT codes.
Consultations
Specialty consultations obtained and their key recommendations.
Condition at discharge
Patient's functional and clinical status — stable, improved, unchanged.
Discharge medications
Full medication list with reconciliation showing dose changes from admission.
Follow-up plan
Specific appointments with timeframes (e.g., "PCP in 7 days, cardiology in 14 days").
Patient instructions
Plain-language guidance — diet, activity, when to call, when to go to ED.
Code status
Resuscitation preference at time of discharge.
Deadlines and regulations
- →CMS Conditions of Participation: within 30 days of discharge.
- →Joint Commission expectation: <24-48 hours, signed by attending.
- →Most hospitals\' bylaws: 24 hours for routine, immediate for transfers to higher level of care.
- →Information blocking (Cures Act): patient has right to read it once finalized.
- →Quality scoring: late or incomplete discharge summaries affect HCAHPS readmission and care-coordination metrics.
Free printable template
--- DISCHARGE SUMMARY --- Patient name: MRN: DOB: Sex: Admission date: Discharge date: Length of stay: Attending: Service: Discharge to: [Home / SNF / Rehab / Hospice / etc.] ADMISSION DIAGNOSIS: DISCHARGE DIAGNOSES (in order of importance): 1. 2. 3. PROCEDURES PERFORMED: Date / Procedure / CPT code: CONSULTATIONS: Service / Recommendations summary: HOSPITAL COURSE: [Chronological narrative — admission presentation, key events, treatments given, complications and how they were managed, response, current status] CONDITION AT DISCHARGE: Functional status: Vitals at discharge: Pain level: Mental status: DISCHARGE MEDICATIONS (with reconciliation): CONTINUED FROM HOME: CHANGED: NEW: DISCONTINUED: DIET: ACTIVITY: WOUND/DRESSING CARE (if applicable): FOLLOW-UP APPOINTMENTS: PCP: (within ___ days) Specialist 1: (within ___ days) Specialist 2: (within ___ days) Labs / imaging: PATIENT INSTRUCTIONS (plain language): Watch for: Call doctor if: Go to ED if: CODE STATUS AT DISCHARGE: [Full code / DNR / DNI / etc.] ATTENDING SIGNATURE / DATE:
Example 1 — Medical inpatient (CHF exacerbation)
Patient: J.M., 72M · Admission: 2026-04-21 · Discharge: 2026-04-25 (LOS 4 days) · Service: Hospitalist
Admission diagnosis
Acute on chronic systolic heart failure exacerbation.
Discharge diagnoses
1. Acute on chronic systolic heart failure (EF 30%), I50.23. 2. Atrial fibrillation, paroxysmal, I48.0. 3. Type 2 diabetes mellitus, E11.9. 4. Stage 3 CKD, N18.30. 5. Hypertension, I10.
Hospital course
Mr. J.M. presented to ED with 3 days of progressive dyspnea, orthopnea, and 6 kg weight gain. Initial BNP 4,820 (baseline 1,200), creatinine 1.8 (baseline 1.4), CXR with pulmonary edema. Started on IV furosemide 80 mg BID, with net negative 1.5–2 L/day for 4 days. Total weight loss 6.2 kg. Symptoms resolved by day 3. Atrial fibrillation persisted with controlled rate on metoprolol; CHA₂DS₂-VASc 4, anticoagulation continued (apixaban 5 mg BID). Started on dapagliflozin 10 mg daily prior to discharge for additional mortality benefit. Cardiology consulted — recommended outpatient referral for ICD candidacy evaluation given persistent EF < 35%.
Condition at discharge
Stable. Vitals: BP 118/72, HR 68, SpO₂ 96% RA. Functional status returned to baseline (ambulating with cane). No SOB at rest.
Discharge medications (reconciled)
Continued: apixaban 5 mg BID, metformin 1000 mg BID, atorvastatin 40 mg QHS, lisinopril 20 mg daily. Changed: furosemide increased from 40 mg to 80 mg PO daily; metoprolol succinate increased from 25 mg to 50 mg daily. New: dapagliflozin 10 mg daily; potassium chloride 20 mEq daily. Discontinued: none.
Follow-up
PCP in 7 days for weight check and BMP. Cardiology in 14 days. Heart failure clinic enrollment offered, scheduled.
Patient instructions
Weigh yourself every morning. Call doctor if weight goes up by 3 lb in one day or 5 lb in a week. Call doctor for new shortness of breath, swelling, or chest pain. Go to the ED for severe shortness of breath at rest, fainting, or chest pain.
Code status
Full code (confirmed during hospitalization).
Example 2 — Surgical inpatient (lap appy)
Patient: S.K., 28F · Admission: 2026-04-26 · Discharge: 2026-04-28 (LOS 2 days) · Service: General Surgery
Admission diagnosis
Acute uncomplicated appendicitis (K35.80).
Discharge diagnoses
1. Acute uncomplicated appendicitis, status post laparoscopic appendectomy. No complications.
Procedures performed
2026-04-26 — Laparoscopic appendectomy (CPT 44970). Surgeon: Dr. P. Lin. Anesthesia: GETA, uneventful.
Hospital course
Ms. S.K. presented to ED with 18 hours of RLQ pain, anorexia, and low-grade fever. CT showed enlarged appendix with surrounding stranding, no perforation. Underwent uncomplicated laparoscopic appendectomy on hospital day 1. Standard post-operative pathway: clear liquids advanced to regular diet POD 1, ambulating on POD 1, pain controlled with oral acetaminophen and ibuprofen. Tolerated diet, voiding without difficulty. Discharged POD 2.
Condition at discharge
Stable. Tolerating regular diet. Pain 2/10 on oral analgesics. Incisions clean, dry, intact.
Discharge medications (reconciled)
New: acetaminophen 1000 mg PO Q6H × 5 days; ibuprofen 600 mg PO Q6H × 5 days; oxycodone 5 mg PO Q6H PRN severe pain × 5 days (#15 tablets, no refill). Continued: oral contraceptive (per home).
Follow-up
General surgery clinic in 14 days for incision check. PCP as needed.
Patient instructions
No heavy lifting (over 10 lb) for 2 weeks. May shower, no soaking baths for 7 days. Watch incisions for redness, warmth, drainage, or fever > 38.3°C. Call surgeon for those symptoms or for worsening pain. Go to ED for severe abdominal pain, vomiting, or fever > 39°C.
Code status
Full code.
Common pitfalls that delay billing
No medication reconciliation
Listing discharge meds without showing what changed from admission. Reconciliation is the single most-audited element.
Vague hospital course
"Patient improved with treatment" tells the receiving provider nothing. Walk through events chronologically.
Missing follow-up dates
"Follow up with PCP" without timeframe is not actionable. Specify 7 days, 14 days, etc.
Patient-illegible instructions
Medical jargon makes instructions useless. Aim for 6th-8th grade reading level. Read it aloud as a test.
No code status
Required by Joint Commission. If you didn't discuss it, document why (e.g., patient declined).
How AI scribes generate discharge summaries
AI scribes pull from the entire admission — not just one note. PatientNotes can stitch together admission H&P, daily progress notes, consult recommendations, and discharge orders into a single structured discharge summary. Med-rec is the highest-leverage piece: an AI that reconciles admission vs discharge meds and flags discrepancies before the attending signs is doing real work.
Frequently asked questions
How fast must a discharge summary be completed?
CMS requires a discharge summary within 30 days of discharge. Most hospitals require less — Joint Commission expectation is < 24-48 hours, and many EHRs auto-flag missed deadlines. For complex inpatient stays, 24 hours is the practical standard.
Who reads the discharge summary?
The next-care provider (PCP, specialist, SNF receiving team), the patient, and quality / billing reviewers. Each audience needs different information density: clinicians need the hospital course; patients need the instructions; reviewers need the dx + procedures.
What's the difference between discharge summary and discharge instructions?
Discharge summary is for clinicians (hospital course, dx, procedures, meds, follow-up). Discharge instructions are for patients (what to watch for, when to call, when to go to ED, how to take meds). Both are required; they are not the same document.
Does Medicare require a discharge summary?
Yes. CMS Conditions of Participation §482.43 require a discharge summary for inpatient stays. The summary must contain the patient's clinical status, follow-up needs, and instructions. Failure to complete affects hospital quality scores and reimbursement.
Can a resident sign the discharge summary?
Generally yes for the body of the summary, but the attending physician must co-sign per most hospitals' bylaws and per CMS rules. Local policy varies — verify with your medical staff office.
Is dictation acceptable?
Yes — most hospitals accept dictated, transcribed, or AI-generated discharge summaries. The format and content requirements are the same regardless of input method.
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