Discharge Summary — Basic Template

#discharge #inpatient #documentation #note-writing

This template produces a complete, structured discharge summary for a primary care handoff. Paste in a de-identified clinical narrative, and Claude will generate a professional summary in the standard sections expected by most receiving physicians.

Prompt Template

Discharge Summary — Basic Claude 
You are an experienced hospitalist physician writing a discharge summary for the receiving outpatient primary care provider.
Using the clinical information provided below, write a complete and concise discharge summary with the following sections:
1. Admission Diagnosis
State the primary reason for admission and any secondary diagnoses addressed during the hospitalization.
2. Hospital Course
Provide a concise narrative (3–5 sentences) covering: key clinical events, decisions made, procedures performed, consultations obtained, and the clinical trajectory during the stay.
3. Significant Results
List the most clinically important labs, imaging, pathology, or procedure findings. Format as a short bulleted list.
4. Discharge Medications
List only medications that CHANGED during this admission:
    

  • Started: [medication, dose, frequency, duration/indication]
    • 

  • Stopped: [medication, reason if known]
    • 

  • Dose-adjusted: [medication, old dose → new dose]
    • 

5. Discharge Condition
One sentence: stable / improved / at baseline / guarded.
6. Follow-up Instructions
    

  • Scheduled appointments (specialty, timeframe)
    • 

  • Pending results (what, expected timing, who reviews)
    • 

  • Activity and dietary restrictions if applicable
    • 

7. Return Precautions
List 3–5 specific symptoms or signs that should prompt the patient to seek emergency care.
Be concise and clinically precise. Avoid filler language. Use standard medical abbreviations where appropriate.
CLINICAL INFORMATION:
[Paste your de-identified clinical notes, discharge checklist, or structured summary here]

Customization Guide

ElementHow to Adjust
Reading levelAdd: “Write the follow-up section at a 6th grade reading level”
LengthAdd: “Keep the hospital course to 2 sentences maximum”
SpecialtyAdd: “This is a cardiology admission. Emphasize cardiac-specific follow-up.”
FormatAdd: “Format the entire summary as a single flowing paragraph instead of sections”

Notes

  • This template is optimized for general medicine admissions. See specialty-specific templates for cardiology, oncology, and surgical discharges.
  • For complex discharges (e.g., new cancer diagnosis, major surgery), the AI output will require more editing — use it as a structural skeleton rather than a final draft.
  • Always verify the medication section against the actual medication reconciliation before signing.

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