Templates / Nursing discharge note: Free template and guide

Practice Management Tips

Nursing discharge note: Free template and guide

Free PDF • 1 page, print-ready • Clinician-reviewed

Despina Petrushevska Last updated November 4, 2026 Reviewed by Dr. Vanja Kitanova

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A nursing discharge note is the nursing record of a patient's condition, medications, instructions and follow-up at the point they leave your care. It tells the next provider what was done and what happens next, and it complements the physician discharge summary without repeating it. Incomplete or late discharge documentation is a recognized contributor to missed follow-up and readmission risk. This guide covers what the note must contain, how to write it step by step and a worked example, with a free template to download.

Template details

Template type

Guide

Format

Printable PDF, 1 page

Fields to complete

12 fields

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Practice Management Tips

Key takeaways

A nursing discharge note records the patient’s status, medications, vitals and instructions at the moment of discharge.

It is a nursing document, distinct from the physician discharge summary, though the two should agree.

Medication reconciliation and written discharge instructions are the sections most often left incomplete.

The free template covers seven core sections but has no vital-signs or signature section, so add both if your policy requires them.

Pabau, the practice management platform we build, captures the discharge note as a structured digital form on the patient record.

What is a nursing discharge note?

A nursing discharge note is the nursing team’s record of a patient’s condition and care plan when they leave a facility or service. It captures the clinical status at discharge, the medications the patient is going home on, and the instructions and follow-up they need.

The physician discharge summary is a separate document. It focuses on the diagnosis, the treatment course and the medical plan. The nursing note focuses on the patient’s functional status, their understanding of the instructions, and the practical support they need at home.

Nursing documentation is the nursing team’s own responsibility, so the two records should agree without duplicating each other. The comparison below shows how the work splits.

What the note must cover

A complete nursing discharge note covers the same core areas in every setting. Each element has a clinical reason for being there.

• Patient condition at discharge: The clinical and functional status, including mobility and ambulation, so the next provider knows what the patient can manage.
• Vital signs: The most recent set, or a recorded “within normal limits” entry where that applies, to show the patient was stable on leaving.
• Medication reconciliation: Every medication the patient is taking at discharge, with changes, stops and new prescriptions listed clearly.
• Discharge instructions: The written instructions given to the patient, and a record that they were reviewed and understood.
• Follow-up appointments: The date, provider and purpose of each follow-up, so the patient knows what comes next.
• Nursing assessment and care plan: The key findings from the admission assessment and the ongoing care needs that carry forward.

The written instructions often go home as a separate handout, and our guide to patient discharge instructions covers what to put in it. The exact requirements vary by setting and by state. Check your facility policy and your state board of nursing guidance before you finalize a template.

How to write a nursing discharge note

Writing the note is faster when you work through it in the order the information becomes available. Start while the patient is still with you, not after they have gone.

1. Confirm the discharge order and the discharge time, and record the patient’s condition and orientation at that moment.
2. Record the final set of vital signs, noting any abnormal values and the action taken.
3. Reconcile medications against the discharge order, flagging new, changed and stopped medications.
4. Document the written instructions you reviewed, and the patient’s or caregiver’s understanding in their own terms.
5. Record each follow-up appointment with its date, provider and purpose.
6. Sign the note and confirm it is filed to the patient record before the handover is complete.

Many nurses use a SOAP note structure for the clinical narrative, with subjective and objective findings followed by the assessment and plan. This format works well for the body of the note, provided the discharge-specific sections are still clearly labeled.

What’s in the free template

The free template gives you seven sections, each with space for free-text notes. It has no vital-signs or signature section, so the last two rows below are recommended additions to make yourself. Adapt the rest to your setting.

A worked example: discharge after hip replacement

Consider a 68-year-old patient discharged from a surgical ward after a hip replacement. The patient is mobile with a walker, afebrile and oriented. The note records the final vital signs as within normal limits and lists the new anticoagulant with its dose and duration.

It also states that the patient and their daughter reviewed the written instructions, including wound care and when to seek help. The follow-up section records a physical therapy referral and a wound check at a primary care follow-up within seven days.

The example is only illustrative. Your own notes should reflect the patient in front of you, their orders and your facility’s policy.

Where discharge planning fits

Discharge planning starts at admission. The nursing assessment identifies the support a patient will need, and the care plan tracks progress against it. The discharge note hands those plans over to the next setting. That might be home, a community team or a skilled nursing facility.

A discharge planning checklist started at admission keeps those needs visible until the day the patient leaves. The Re-Engineered Discharge (RED) program, later published as an AHRQ toolkit, breaks discharge into defined steps. One of them is a written care plan for home.

In a randomized trial published in 2009, patients who went through RED had about 30% fewer emergency visits and readmissions within 30 days. That result reflects the whole discharge process, not the nursing note on its own.

How requirements change by setting

Discharge note requirements change with the setting. A skilled nursing facility must meet CMS discharge planning conditions for its residents, which shape what the note must cover. Home health and outpatient practices often work to different local policy and to their own state board guidance.

Because the rules differ by state and by facility, treat any single format as a starting point. Confirm the specific requirements with your state board of nursing and your compliance lead before you adopt a template across sites.

Common documentation mistakes

The same errors turn up again and again, which makes them easier to prevent. Many come from completing the note after the patient has left.

• Medication reconciliation left incomplete: A stopped medication that isn’t recorded can lead to the patient taking it at home. Reconcile against the discharge order before the patient leaves, using a medication reconciliation form if your team keeps one.
• Instructions recorded but not confirmed: Note that the patient or caregiver reviewed and understood the instructions, not just that they were given.
• Vital signs without context: An abnormal value with no recorded action reads as an oversight. Record what you did.
• Follow-up without dates: “Primary care follow-up in two weeks” is harder to act on than a booked date and provider.

A template prompts every section, but it can’t check what goes into them. A completed field doesn’t prove the medication list is correct.

How Pabau keeps discharge notes on the patient record

On paper, a discharge note gets printed, filled in by hand and scanned into the record later. Until someone scans it, the next clinician can’t find it.

Pabau’s patient intake software lets you rebuild the template as a digital form with the same seven sections. The nurse completes it on a tablet or computer, and it saves straight to the patient record as a structured form.

You can add the vital-signs and signature fields your policy needs while you build it. The digital version then covers more than the PDF, and the next clinician finds the note alongside the rest of the patient’s history.

Keep every discharge note on the patient record

Pabau’s digital forms turn your discharge template into a structured form that saves to the patient record. The next clinician finds the note where they already look.

Book a demo

Conclusion

A discharge note does its job in the first week after the patient leaves. Write it before they go, reconcile the medication list against the discharge order, and give every follow-up a date and a provider.

The free template gives you seven core sections. Add vital signs and a signature line before you roll it out, and check it against your state board guidance.

Book a demo to see how Pabau keeps your completed discharge notes on the patient record, ready for the next clinician.

Continue your research

Need a broader discharge form? Patient discharge form template covers the administrative side of discharge alongside the clinical note.

Planning the discharge from admission? Discharge plan template tracks the support a patient needs before the day they leave.

Documenting the start of the stay? Admission nursing note shows how to record the assessment your discharge note later closes out.

Writing narrative entries between admission and discharge? Nursing narrative note template gives you a structure for shift-by-shift notes.

Confirming follow-up in writing? Patient follow-up letter template puts the follow-up date and provider in the patient’s hands.

Frequently asked questions