Writing a high-quality discharge summary is a vital skill for any resident (junior) doctor. It isn’t just paperwork; it is the primary communication bridge between hospital care and the community.
A discharge summary is often the only piece of information a GP receives regarding a patient’s hospital stay—whether that stay lasted 24 hours or three months. Its primary purpose is to ensure the GP understands the key decisions made and what actions they need to take next.
A great summary focuses on Communication. There are four primary reasons to get this right:
For the GP: To outline specific clinical actions required in the community.
For the Patient: To empower them with a record of their care (always provide a copy to the patient).
For Hospital Colleagues: To provide a reference for future admissions or emergency visits.
For the Record: To serve as a formal medicolegal document of the admission.
Be Concise: GPs don’t have time for “War and Peace.” Avoid copy-pasting every blood result or scan report. Focus on the highlights.
Structure Your Prose: Use short paragraphs (3–4 sentences).
Filter Information: Only include “relevant negatives.” If a negative result doesn’t change the diagnosis or management, leave it out.
Avoid Jargon: Use precise medical terms but avoid vague slang like “urosepsis” (it’s a UTI). Be clear and clinical.
A professional summary should follow a logical flow. Ensure the Consultant’s name is prominent at the top, as they hold ultimate medicolegal responsibility.
| Section | Key Information to Include |
| 1. Patient Details | Ward, department, admission date, and discharge/transfer date. |
| 2. Diagnoses | The primary diagnosis and relevant comorbidities. Include significant positive investigation results. |
| 3. Management | A summary of treatments (e.g. IV antibiotics), operations, complications, and specialist referrals. |
| 4. Medication List | A clear list of discharge drugs. Highlight which were started or stopped and list all allergies. |
| 5. Follow-up Plan | Specific dates/locations for clinics. Note: Do not ask GPs to organise follow-ups for hospital teams. |
| 6. Pending Results | List any outstanding tests. It is your job—not the GP’s—to monitor these results. |
| 7. Contact Info | Your name, rank, bleep number, and the consultant you work under. |
Avoid asking GPs to organise complex imaging (like MRIs) or to arrange follow-ups with your own surgical or medical teams. These tasks should be completed before the patient leaves the hospital.
Actionable Steps for the GP and Patient – if they are essential.
Be clear what you want them to do.
Clearly separate the “to-do” list:
For the GP: e.g., “Please repeat U&Es in 7 days to monitor the new ACE inhibitor.”
For the Patient: e.g., “Continue the blood-thinning injections for 10 days; the district nurse will visit tomorrow.”
Writing a concise, accurate summary is an act of professional courtesy. Remember: one day, you might be the one receiving a summary on a busy afternoon. You’ll certainly appreciate a job well done.
Review article (Ng, 2025)
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