How to write a good discharge summary: a primer for junior physicians.

Abstract

A discharge summary is an important clinical document that summarizes a patient's clinical information and relevant events that occurred during hospitalization. It serves as a detailed handover of the patient's most recent and updated medical case records to general practitioners, who continue longitudinal follow-up with patients in the community and future medical care providers. A copy of the redacted/abbreviated form of the discharge summary is also usually given to patients and their caregivers so that important information, such as diagnoses, medication changes, return advice, and follow-up plans, is clearly documented. However, in reality, as discharge summaries are often written by junior physicians who may be inexperienced or have lacked medical training in this area, clinical audits often reveal poorly written discharge summaries that are unclear, inaccurate, or lack important details. Therefore, in this article, we sought to develop a simple "DISCHARGED" framework that outlines the important components of the discharge summary that we derived from a systematic search of relevant literature and further discuss several pedagogical strategies for training and assessing discharge summary writing.