Discharge summary template: Free download and clinical guide

Key takeaways

A discharge summary is the final clinical document that records a patient’s diagnosis, treatment and post-discharge care plan.

Required fields include admission history, discharge diagnosis, treatment summary, medications, pending results, follow-up instructions and the attending clinician’s signature.

Incomplete or late summaries drive medication errors, missed follow-ups and readmissions, so timing matters as much as content.

Aim to finish the summary within 24 hours of discharge, while the clinical detail is still fresh.

Structured templates and automated note workflows help clinicians document faster and stay aligned with CMS and Joint Commission standards.

A discharge summary is the document that carries a patient from one care setting to the next. It tells the receiving clinician what happened, what the patient is taking, and what still needs to be done.

This guide walks through every required section, with worked examples from hospital medicine, physical therapy and behavioral health. The free template above gives you the same structure as a form you can fill in today.

What is a discharge summary?

A discharge summary is a clinical document completed at the end of a patient’s care episode. It sets out why the patient presented, what treatment was provided, how they responded, and what happens next.

It serves three audiences at once. The primary care provider uses it to act on the specialist’s findings. The patient uses it to understand their medications and self-management responsibilities.

Your practice is the third audience. The summary is the record that demonstrates continuity of care to The Joint Commission and to payers. It is also the first document requested when a transition is questioned.

• Hospital: Documents the inpatient admission, procedures and discharge instructions for the primary care handoff.
• Physical therapy: Summarizes functional progress toward goals and the home program, which matters in physical therapy practices billing by episode.
• Behavioral health: Outlines the treatment episode, interventions, medications and psychiatric follow-up, the core record in mental health practices.
• Primary care: Closes an episode of care after a procedure or acute illness with clear continuity instructions.

Key components to include

Every summary, whatever the specialty, contains the same core sections. These are mandated by The Joint Commission, CMS, state licensing boards and professional associations such as the American Physical Therapy Association.

Worked examples across care settings

The core structure above holds everywhere, but the emphasis and the clinical detail change. Here is what a completed document looks like in two very different settings.

Hospital example

Admission history: 68-year-old male presenting with acute chest pain and dyspnea. EKG showed ST elevation in the inferior leads.

Discharge diagnosis: Acute ST-elevation myocardial infarction, treated with percutaneous coronary intervention to the right coronary artery. Ejection fraction 42%.

Treatment summary: PCI with stent placement, then admission to the coronary care unit for arrhythmia monitoring. Troponin peaked at 8.5 ng/mL on day 2. Echocardiography showed inferior wall hypokinesis. Discharged on day 3 in stable condition.

Medications: Aspirin 81 mg daily, clopidogrel 75 mg daily for 12 months, metoprolol 50 mg twice daily, lisinopril 10 mg daily, atorvastatin 80 mg daily.

Follow-up: Cardiology in 1 week, stress testing at 6 weeks, and primary care in 1 week for medication review.

Physical therapy example

Admission history: 52-year-old female, day 3 after total knee replacement. Goal: restore knee range of motion and functional mobility for independent ambulation.

Progress toward goals: Achieved 95° knee flexion against a 100° target, with the extension lag resolved from 20° to 5°. Ambulation progressed from parallel bars to crutches, then to a single point cane. Stairs managed independently with a rail.

Status at discharge: Discharged home after 12 sessions over 4 weeks. Range of motion adequate for independent daily activities. Pain 2/10 with activity.

Home program: Quad sets three times daily, straight leg raises, standing hip abduction and step-ups, issued as a written home exercise program. Continue for 6 weeks, then reassess.

Follow-up: Return to therapy if range of motion plateaus or pain increases. Orthopedic surgeon at the 6-week postoperative mark.

How to write one, step by step

The strongest summaries are written within 24 to 48 hours of discharge, while the clinical detail is fresh. Here is how to work through it efficiently.

1. Gather the record. Collect the admission note, treatment notes, labs, imaging reports and the medication list. Having everything in one place prevents omissions.
2. Write the admission history. Two or three sentences on the chief complaint and reason for presenting. A completed medical information form usually supplies the history you need.
3. State the discharge diagnosis. Include the primary diagnosis, plus any secondary diagnoses or complications that emerged during care. Add the ICD-10 code where coding is required.
4. Summarize the treatment. Describe procedures, medications given and key clinical milestones. Be specific, so “pain decreased from 8/10 to 2/10” rather than “patient improved”.
5. Document medications at discharge. List every medication the patient leaves with: name, dose, frequency, route and special instructions such as “take with food”.
6. Note pending results. Flag labs, imaging or cultures still outstanding. State when the patient should expect them and how they will be notified.
7. Write the follow-up plan. Name the next clinician, the timeframe and any referrals. Spell out when to call the office and when to go to the emergency room.
8. Add discharge instructions. Cover activity restrictions, diet, wound care where relevant, and the red-flag symptoms that warrant urgent contact.
9. Sign and date. Authenticate the document with your clinical credentials and the discharge date.

Best practices and common mistakes to avoid

A well-structured summary reduces readmissions and improves outcomes. These are the failures that undermine both safety and compliance.

• Incomplete medication list: Omitting doses, frequencies or contraindicated drugs during the transition. A prescription management system reconciles medications for you.
• Vague follow-up instructions: “Follow up as needed” leaves both the patient and the receiving clinician guessing. Name dates and practices instead.
• Delayed completion: Summaries written weeks later lose accuracy and stall care coordination. Aim for 24 hours.
• Boilerplate language: Templates help, but generic text such as “patient tolerated procedure well” adds nothing. Personalize it with the patient’s own outcomes.
• Missing pending results: An unflagged lab or scan leaves the receiving clinician with nothing to chase.
• Absent red-flag warnings: Instructions without a “call us if” statement leave families unprepared for complications.

CPT codes and billing for discharge day management

In hospital and ambulatory settings, discharge day management is a billable service. Two CPT codes apply, 99238 and 99239, and the split between them is based on time and complexity.

Documentation rule: CMS requires explicit time documentation on the day of discharge for 99238 and 99239. Completing the summary is not enough on its own. Note the minutes spent and the complexity level, and enter them the same day, because retrospective time entries are audited closely.

Time-based codes shift with annual updates, so check the current year’s guidance with the American Medical Association or your payer. A medical coding cheat sheet is a useful desk reference for the rest of the episode.

How Pabau streamlines discharge documentation

Most practices rebuild the same document from scratch every time. A clinician reads back through the chart, retypes the treatment course into prose, then copies medications across by hand. That is where the omissions creep in.

Practice management software like Pabau turns that into a structured form. Digital forms embed the discharge template directly in the patient record, so your clinician fills defined fields instead of writing prose. Pabau Scribe, our AI scribe, drafts the narrative sections from dictation.

The finished summary is then shared from the patient record with the primary care provider and the patient. It is stored against the episode for audit. Clinicians get their documentation time back, and the receiving clinician gets the handoff on the day of discharge.

See how Pabau automates clinical documentation

Built-in discharge templates and Pabau Scribe, our AI scribe, save your practice hours each week and keep every note audit-ready.

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Conclusion

The discharge summary is your last clinical communication with both the patient and the next clinician. If it is late, thin, or missing a medication, the patient carries that error into the next setting.

Fixing that rarely means writing better prose. A structured form with defined fields is faster to complete, and much harder to leave half-finished. Start with the template above and keep the same section order in every setting you work in.

The trade-off worth remembering is that structure only pays off if the document actually reaches the receiving clinician the same day. Book a demo to see how Pabau shortens documentation time and delivers each summary automatically.

Continue your research

Need the history before you can write the summary? The medical information form captures conditions, allergies and current medications in one pass.

Onboarding patients into an episode of care? The new patient questionnaire collects the baseline detail your discharge documentation later depends on.

Discharging a therapy patient home? The home exercise program gives them a written plan to follow after their last session.

Monitoring neurological status before discharge? The neuro checks assessment standardizes how those observations are recorded.

Coding the episode as well as documenting it? The medical coding cheat sheet keeps the common codes within reach.

Frequently asked questions