How to write an effective patient discharge letter - with a worked example!

Writing a clear and effective discharge summary is an essential skill for junior doctors and medical students. This document ensures continuity of care by providing critical information to General Practitioners (GPs), community healthcare teams, and the patient. Below, I outline the key steps, essential components, and an example of a well-structured discharge summary.

Preparing to Write the Discharge Summary

Before drafting the discharge summary, confirm the following:

• Patient's discharge status – Ensure the patient is medically fit for discharge.
• Gathering information – Access key documents, including:
  • Admission notes (reason for admission).
  • Ward round notes (important clinical decisions).
  • Results of investigations (scans, blood tests).
  • Allied health input (physiotherapy, occupational therapy).
• Patient communication – Inform the patient of their discharge and ensure they understand their follow-up plan.

Key Components of a Discharge Summary

1. Patient Information

• Full name
• Date of birth
• Hospital number / NHS number
• Date of admission and discharge

2. Reason for Admission

Clearly state why the patient was admitted in a single sentence.

Example:
Admitted on 05/02/2024 with left-sided pneumonia causing hypoxia and increased work of breathing.

3. Hospital Management Summary

A brief overview of the hospital stay, including:

• Major treatments received
• Significant interventions (e.g., surgery, antibiotics)
• Key decisions made

Example:
The patient was treated with IV antibiotics for 5 days and transitioned to oral antibiotics after clinical improvement. Oxygen therapy was weaned off before discharge.

4. Significant Test Results

• Include abnormal blood tests and relevant imaging.
• No need to list normal results.

Example:

• CXR: Left lower lobe consolidation
• CRP: 120 (improved to 20 before discharge)
• WCC: 14.5 (returned to normal range)

5. Medication Changes

• New medications started
• Medications stopped
• Any dose adjustments

Example:

• Amoxicillin 500mg TDS for 5 days (NEW)
• Stopped furosemide as no ongoing fluid overload

6. Follow-Up Instructions

Clearly specify:

• Any tests needed (e.g., blood tests, imaging)
• Outpatient appointments
• Urgent issues for the GP to monitor

Example:

• Please recheck CRP in 1 week to ensure infection resolution.
• Follow-up with respiratory clinic in 4 weeks.

7. Patient Summary (Layperson Explanation)

Write a patient-friendly explanation of their diagnosis, treatment, and follow-up.

Example:
"You were admitted due to a chest infection affecting your left lung. You received antibiotics in the hospital, and your breathing improved. Continue taking your prescribed antibiotics, and your GP will check your infection markers next week. If you feel worse or develop a fever, contact your GP or NHS 111."

8. Contact Information

Provide your details in case further clarification is needed.

Example:
Dr. [Your Name]
Foundation Year 1 Doctor, [Hospital Name]
Contact: [Email or Hospital Number]

Example of a Discharge Summary

Patient Details:
Name: John Smith
DOB: 15/08/1965
Hospital Number: 987654
Date of Admission: 05/02/2024
Date of Discharge: 10/02/2024

Reason for Admission

Admitted with left-sided pneumonia causing respiratory distress and hypoxia.

Hospital Management

• Treated with IV co-amoxiclav and transitioned to oral amoxicillin.
• Required oxygen therapy, which was gradually weaned off.
• Improved clinically and mobilizing well before discharge.

Significant Results

• CXR: Left lower lobe consolidation
• CRP: 120 (down to 20 before discharge)
• WCC: 14.5 (normalized)

Medication Changes

• Amoxicillin 500mg TDS for 5 days (NEW)
• Stopped furosemide (no longer needed)

Follow-Up Instructions

• GP to recheck CRP in 1 week.
• Outpatient respiratory follow-up in 4 weeks.

Patient Summary

"You were admitted due to a chest infection. You received antibiotics and oxygen support, and your breathing improved. You will need a blood test next week to check your infection markers. If you develop a fever, worsening cough, or breathing problems, contact your GP or NHS 111."

Contact Information

Dr. [Your Name]
Foundation Year 1 Doctor, [Hospital Name]
Contact: [Your Contact]

Final Tips for Writing a Good Discharge Summary

✔ Be clear and concise – Avoid unnecessary medical jargon.
✔ Highlight important follow-up actions – Ensure the GP knows what to monitor.
✔ Use bullet points – Improves readability.
✔ Ensure accuracy – Double-check medication changes and test results.
✔ Make it patient-friendly – The patient summary should be easy to understand.

Conclusion

A well-structured discharge summary is essential for patient safety and continuity of care. Following this guide will help you write clear, concise, and informative summaries that assist both GPs and patients in managing post-hospital care effectively.