Discharge Summary Template
A structured discharge summary ensures safe handover from hospital to primary care. Use this template as a reference or let WhiteFieldHealth generate it from clinical documentation.
WhiteFieldHealth
Built for reviewable clinical documentation, not generic AI output.
When to use a discharge summary
Discharge summaries are mandatory after every inpatient or day-case admission. They bridge the gap between hospital and primary care, ensuring the GP has complete information about the diagnosis, treatment provided, medication changes, and required follow-up actions. Poor discharge communication is a recognised cause of adverse events and readmissions. This template follows the Professional Record Standards Body (PRSB) discharge summary standard used across NHS trusts.
Worked example: Post-cholecystectomy discharge
Patient Demographics
Name: Mrs Helen M. Clarke. DOB: 22/07/1965 (age 60). NHS Number: 654 321 0987. Address: 15 Orchard Lane, Reading, RG1 5BN. Ward: Surgical Day Unit, Royal Berkshire Hospital.
Admission Details
Date of admission: 10/03/2026. Date of discharge: 11/03/2026. Length of stay: 1 night. Admitting consultant: Mr P. Okonkwo, General Surgery. Method of admission: Elective. Reason for admission: Elective laparoscopic cholecystectomy for symptomatic gallstones.
Diagnosis
Primary: Cholelithiasis with recurrent biliary colic. Secondary: Mild fatty liver disease (incidental finding on pre-operative ultrasound). Past medical history: Type 2 diabetes mellitus, hypertension, osteoarthritis of the right knee.
Procedures
Laparoscopic cholecystectomy performed 10/03/2026 under general anaesthesia. Findings: Chronically inflamed gallbladder with multiple cholesterol stones. Cystic duct and artery identified and clipped. No intraoperative complications. Estimated blood loss <50 mL. Specimen sent for histology.
Medications on Discharge
1. Paracetamol 1 g QDS for 5 days (new — post-operative analgesia). 2. Co-codamol 30/500 two tablets QDS for 3 days (new — post-operative analgesia). 3. Ramipril 2.5 mg OD (continued). 4. Metformin 500 mg BD (continued). Stopped: Nil. Allergies: Penicillin (rash).
Follow-up Plan
1. Surgical outpatient review in 6 weeks (appointment to follow by post). 2. Histology results to be reviewed at outpatient appointment. 3. Wound check with practice nurse at GP surgery in 7–10 days. 4. Patient advised to contact surgical assessment unit if: fever >38°C, increasing abdominal pain, jaundice, or wound discharge.
GP Actions
1. Review wound at 7–10 days post-discharge. 2. Check LFTs in 4 weeks if not already arranged. 3. Resume routine diabetes and hypertension monitoring. 4. Histology follow-up will be managed by surgical team — no GP action required unless patient fails to attend outpatient review.
Tips for effective discharge summaries
Reconcile medications
Clearly mark new, continued, and stopped medications. Ambiguous discharge lists are a leading cause of medication errors after hospital stays.
Separate GP actions
Give the GP a dedicated list of tasks rather than burying them in the narrative. This prevents items being missed during handover.
Include safety-netting advice
Document the warning signs you told the patient about and when to seek urgent help. This protects both patient and clinician.
Note pending results
Flag any investigations sent but not yet reported (histology, cultures) and who is responsible for actioning the results.
Send within 24 hours
NHS best practice recommends the discharge summary reaches the GP within 24 hours of discharge to enable safe continuity of care.
How WhiteFieldHealth generates discharge summaries automatically
WhiteFieldHealth extracts diagnosis, procedure details, and medication changes from the clinical record and structures them into a discharge summary ready for review. Medication reconciliation is handled automatically, flagging new additions, stopped drugs, and potential interactions using BNF and NICE guidance data from our AI medical scribe pipeline.
Suitable for hospital teams and NHS trusts receiving discharge information. See pricing for plan details.
Generate discharge summaries automatically
Produce structured discharge summaries with automatic medication reconciliation and follow-up task extraction.