How to write a discharge summary
How you can help improve the continuity of patient care
- By: Elizabeth Stopford, Sean Ninan, Nick Spencer
Writing discharge summaries is traditionally the task of junior doctors. They may have had formal or informal training about how to do this, but the quality and amount of training vary. Discharge summaries are too often seen as a lower priority for pressurised junior staff, who might not have had sufficient feedback and supervision in how to produce high quality summaries.
The discharge summary should facilitate the safe transition of care from the hospital setting back into the community, delivering information that is both relevant and accurate to aid continuing care. However, errors with discharge summaries are common. In 2002 the Royal College of Physicians audited 149 case notes in five hospitals in England and Wales. Of 87 printed discharge summaries present in the notes, 17% contained no diagnosis, 19% had no procedure, 21% had no follow-up arrangements, and 75% provided the general practitioner (GP) with no information on what