The next time you
complete a Discharge Summary. . .

What you should do when completing a Discharge Summary

  • ✓ Complete a Discharge Summary for all inpatients regardless of Length of Stay
  • ✓ Start the Discharge Summary on Day 1 of the patient's stay
  • ✓ Document course of stay information chronologically
  • ✓ Tailor information to each patient and situation (avoid copy & paste)
  • ✓ Consider what information you would like to receive as a Provider
  • ✓ Be concise and succinct - use point-form lists if appropriate
  • ✓ Update the Discharge Summary prior to a patient's transfer
  • ✓ Ensure patients are assigned to the appropriate MRP in the Electronic Patient Record (EPR)

What you should not do when completing a Discharge Summary

  • ✗ Don't include all laboratory and imaging results (only include those most relevant to follow-up care)
  • ✗ Don't use abbreviations and medical acronyms
  • ✗ Don't include assumptions or inferences (unless indicated as such)
  • ✗ Don't exceed more than 3 pages
  • ✗ Don't rotate off a unit without updating the patient's Discharge Summary

Reminders:
  • • MRP's/Senior Residents are available to Students/Residents to clarify any questions and provide timely feedback
  • • Patients and external Providers read the Discharge Summary - only include appropriate content

Use the A-B-C Method

Apply the Standard:

  The UHN Standard template will make it more efficient for you to complete a Discharge Summary

Be Concise:

  Only include enough information to ensure continuity of care by the subsequent provider

Communicate:

 Discuss the Discharge Summary with the patient and his or her Circle of Care

A Good Discharge summary
will contain. . .

Check off the list as you go along!

 Patient Demographics

 Visit (Encounter)


 Encounter Location/Organzation
 Diagnosis
 Course While In Hospital



 Alert Indicators
 Discharge Plan




Reference: David Frost, MD, FRCP(C) & Karim Taha, Centre for Excellence in Education and Practice & University of Toronto (2015). Discharge Summary Checklist. Toronto, ON.

Examples

Here are some examples of good discharge summaries

Sample Discharge Summary
from Surgery  
Sample Discharge Summary
from Medicine  
Sample Discharge Summary
from Rehab  

Continuing Professional Development Modules

Select a module below to complete a peer Discharge Summary evaluation. The Continuing Professional Development (CPD) module is eligible for Maintenance of Certification (MOC) credits.
Please ensure you enable editing, content and macros when opening the module.

CPD Module eligible
for MOC credit  
Toronto Rehabilitation
Module  

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