UHN Discharge Summary Template

Your dictated Discharge Summary should follow the UHN template below. Include headings as they are appropriate.
Feel free to check off the list as you go along!

 Patient Demographics
Patient's Name
Patient's hospital Medical Record Number (MRN)
Patient's Gender
 Visit (Encounter)
Date of Admission
Patient's Date of Discharge
Diagnosis most responsible for the patient's course in hospital.
If there is more than one such condition, the one held most responsible for the greatest portion of the length of stay or greatest use of resources
Location where the patient was discharged to.
e.g. Home, Home with Support Services, Transfer to Other Institution (named) or Death
 Diagnosis
Condition(s) that coexist at the time of admission or developed post-admission and:

• Requires treatment, or

• Increases the length of stay by at least 24 hours (regardless of whether they were managed intensively during the stay (e.g. dementia), or

• Significantly affects the treatment received

Pre-existing comorbidities or condition(s) that developed post-admission that did not affect the patient's length of stay
 Course While in Hospital
Symptom(s) for which the patient initially sought treatment and presented with
Succinct summary of the patient's clinical course in hospital. Conclusion of associated investigation
Succinct summary of examinations and tests conducted while in hospital
Procedure(s) and/or treatments(s) carried out during course in hospital
 Alert Indicators
If available, list all relevant allergies and describe reaction
 Discharge Plan
Home medications to be continued, home medications which have been adjusted or discontinued, and newly prescribed medications
Follow-up instructions for patient, include follow-up scheduled appointments, if applicable
Investigations and interventions recommended to be conducted by the receiving provider after the patient has been discharged
Referrals that have been initiated by the sender
Other clinicians who are included in care of patient

Electronic Application Guides

Below are resources to get you started with the UHN Discharge Summary / Electronic Medication Information Transfer Tool (EMITT) Application.

For Pharmacists

Learn about key features and functionalities of the Discharge Summary-EMITT Application


  If printing, change print settings to letter size, double-sided, and along the short edge.

For Prescribers

Learn about key features and functionalities of the Discharge Summary-EMITT Application


  If printing, change print settings to letter size, double-sided, and along the short edge.

Dictated Discharge Summary

Below are reminders and phone prompts when dictating your next Discharge Summary.

  •   For an accurate transcription, clearly state key information including:
  • ✓ Correct patient name
  • ✓ MRN
  • ✓ Visit number
  • ✓ Provider Names: Dictating Provider and Most Responsible Provider (if different)
  • ✓ Recipient Names and locations: cc'ed Providers; exclude Providers documented in the patient's EPR face sheet
  • ✓ Investigational drugs
  •   Site/Location: Select the site of the patient's visit, and not the site that the note was dictated
  •   Expected Turnaround Time: 24 hours
  •   Refer to the Best Practices section for guidelines on completing a good Discharge Summary
  •   Tips to ensure a clear dictated note and an accurate transcription:
  • • Ensure that your surroundings are private to respect patient confidentiality
  • • Ensure that noise levels around you are minimal
  • • Do not use a Speaker Phone or Cell Phone as both transmit background noise
  • • Include a statement in the dictated note to indicate an alternate UHN clinician you may be signing off for

  •   For assistance with the dictation system, contact Transcription Services:
  • • Business Hours: Monday to Friday, 8:00am-4:00pm
  • • Ext. 6000 (onsite at TG, TW, PM)
  • • Switchboard at ext. 0 and request "Transcription Services" (onsite at TR)
  • • 416-340-4800 x 6000 (offsite)
  •   Dictating your Discharge Summary:
  1. Dial 4506 (on site) or (416) 340 - 4506 / (416) 946 - 4506 (offsite)

  2. Enter EPR ID, followed by # sign

  3. Enter password, followed by # sign

  4. Enter 1 to begin a new dictation

  5. Select Site 1 = PM, 2 = TG, 3 = TW, 4 = TR

  6. Enter MRN, followed by # sign

  7. Enter 3, followed by # sign to indicate Report Type as Discharge Summary

  8. To dictate, enter 2; at the beginning of the dictation (or press # for help):

    • Clearly state your name; (Residents/Fellows: indicate Staff MD you are dictating for)

    • State/spell the name and provide address/fax of external MD(s) receiving a copy

  9. For priority notes, when in the body of the dictation, enter *9

  10. To end your dictation and/or dictate another report, enter 8; a job ID will be provided at this time
Commands while Recording
  • 0   Play voice file
  • 1   Pauses any function including record
  • 2   Start or Resume recording process
  • 3   Rewinds 5 seconds and resumes play
  • 4   Forwards 5 seconds and resumes play
  • 5   Forward to end and play
  • 6   Cancel/Erase current dictation and continue (1 to confirm cancel, 0 to continue dictating)
  • 7   Rewind to start and play
  • 8   Save current dictation and start next
  • 9   Identify state/priority note
  • #   Help menu options

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