Discharge Summary Documentation
The discharge summary is a concise account of the patient’s illness, course of treatment, response to treatment, and condition at the time of patient discharge (official release) from the hospital. The summary also includes instructions for follow-up care to be given to the patient or to his or her caregiver at the time of discharge. Because the summary provides an overview of the entire medical encounter, it is used for a variety of purposes, including the following:
- Ensures the continuity of future care by providing information to the patient’s attending physician, referring physician, and any consulting physicians
- Provides information to support the activities of the medical staff review committee
- Provides concise information that can be used to answer information requests from authorized individuals or entities
The discharge summary is the responsibility of and must be signed by the attending physician. If the patient’s stay is not complicated and lasts less than 48 hours or involves an uncomplicated delivery of a normal newborn, a discharge note in place of a full summary is often acceptable.
