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Table 4 Discharge summary template elements

From: Design of an orthopaedic-specific discharge summary

Patient demographics Patient name, MRN
Date of birth
Gender
Primary care provider
Visit Admit date
Discharge date
Most responsible health care provider name and contact information
Name of individual completing summary
Date completed
Discharge location
Death (yes, no)
Encounter location Hospital name
Hospital type
Alert indicators Allergies
Course while in hospital Presenting complaint(s)
Summary of key results, investigators, interventions, and advance directives
Adverse events and complications
Discharge plan All medications at discharge
Follow-up instructions for patient
Follow-up plan recommended to be implemented by the receiving provider
Referrals
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