Discharge Summary: Structure and Sections
Inpatient or ED discharge with diagnoses, treatment, and plan. Notermed's built-in Discharge Summary produces the sections below from what is said during the visit. You read the draft, change anything you want changed, and sign it. Until you sign it, it is a draft and outside the record.
What the Discharge Summary contains
8 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Admission Details
- Admission date
- Admitting diagnosis
- Reason for admission
- 2
Presenting Complaint
- Chief complaint
- Presenting symptoms
- 3
Hospital Course
- Treatment given during the admission
- Procedures performed
- Clinical progress
- 4
Diagnoses
- Primary diagnosis
- Secondary diagnoses and comorbidities managed
- 5
Medications at Discharge
- Medication name, dose, frequency, and duration
- 6
Discharge Condition
- The patient condition at discharge
- 7
Follow-up Plan
- Follow-up appointments
- Investigations still pending
- Instructions given
- 8
Patient Education Provided
- Education given
- Safety-netting advice
A section nobody said anything about is left out of the draft rather than padded. You will not find "not discussed" filling a heading you never covered.
Questions about the Discharge Summary
What sections does the discharge summary contain?
Eight: Admission Details, Presenting Complaint, Hospital Course, Diagnoses, Medications at Discharge, Discharge Condition, Follow-up Plan, and Patient Education Provided.
How are discharge medications recorded?
By name, dose, frequency and duration, as they were stated. The draft is built only from what was said, so nothing joins the list that nobody said out loud or dictated.
What if the hospital course was never described in detail?
Then the summary says what was said and no more. A section nobody covered is left out rather than padded, so the draft does not fill a heading with a course of treatment it was not given.
Does the summary count as the record?
Not until you sign it. Every note is a draft until the clinician reviews it and signs it, and the clinician who signs it remains responsible for the record.
What holds true for your patient data
These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.
A BAA first
We sign a Business Associate Agreement with your clinic before any patient data is processed.
US servers only
Patient data is stored and processed only on servers in the United States.
Encrypted throughout
Recordings, transcripts and notes are encrypted in transit and at rest.
Never training data
Patient conversations are never used to train AI models.
Yours to sign
Every note is a draft until the clinician reviews it and signs it.
Structure reviewed
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
See the Discharge Summary on one of your own visits
Bring a consultation. We will record it, show you the draft in this format, and tell you plainly if Notermed is not a fit yet.