Discharge summaries explained: what each section tells your next doctor

What a discharge summary is for

When you leave hospital after an admission, the treating team writes a discharge summary. It records why you were admitted, what was found, what was done and what should happen next. It is written for the doctors who will look after you afterwards — your family doctor, a specialist, or a doctor you see in an emergency months later — so it is one of the most valuable documents in a medical record.

Because it is a hand-over, the summary is only useful if it reaches the next doctor and if it is accurate. The sections below explain what each part usually contains and what to check.

Dates, reason for admission and presenting complaint

The summary normally starts with the dates of admission and discharge, the admitting department and the consultant responsible. The presenting complaint describes what brought you in — for example, chest pain for two hours or fever and breathlessness for three days. This sets the context for everything that follows.

Diagnoses

The final or principal diagnosis is the main condition that was treated. Secondary diagnoses list other conditions that were found or that affected your care, such as diabetes or kidney disease. Sometimes a diagnosis is described as provisional or suspected when tests are still pending; that wording matters, because it tells the next doctor that the question is not fully settled.

Procedures and key investigations

Procedures include operations, endoscopies, catheter studies and other interventions, usually with the date. Key investigations summarise important blood tests, scans and other studies, often with the most relevant values rather than every result. If an important report — a biopsy result, for instance — was not available at discharge, a good summary says so explicitly and says who will follow it up.

The hospital course

This is a short narrative of the stay: how you responded to treatment, any complications, and any change of plan. It helps a later doctor understand not just the outcome but how the team reached it — for example, why one antibiotic was changed to another.

Condition at discharge

This records how you were when you left: your symptoms, observations such as blood pressure, and whether you could walk, eat and manage independently. It is a baseline against which a later doctor can judge whether you have improved or got worse.

Discharge medicines: the section to check most carefully

Medicines are where hand-over errors are most common. A clear discharge summary lists every medicine you should take after leaving, with the dose and how often, and says which are new, which doses have changed, and which of your previous medicines were stopped. The stopped list matters as much as the new one: continuing an old medicine alongside its replacement can cause harm.

Before you leave, compare the list with what you were taking at home. Ask about anything that is missing, duplicated or unclear, and ask how long each new medicine should be continued.

Common abbreviations in the medicines section

Prescriptions and discharge summaries often use short Latin-derived abbreviations for how often a medicine is taken. Knowing the common ones helps you check the list, but abbreviations vary between doctors and a misread frequency is a well-known cause of medication errors, so ask whenever anything is unclear.

• OD — once a day.
• BD or BID — twice a day.
• TDS or TID — three times a day.
• QID — four times a day.
• HS — at bedtime.
• SOS or PRN — only when needed; a good prescription also states the maximum number of doses.
• AC and PC — before meals and after meals.

Follow-up and warning signs

The follow-up section should say when and where you need to be seen next, which tests should be repeated and when, and what to do if certain symptoms appear. Warning signs are written so that you know when to seek help urgently rather than waiting for the planned visit.

Share it with every doctor who looks after you

Give a copy to your family doctor and to any specialist who treats you regularly, even when the admission seems unrelated to their care. A blood-pressure medicine stopped during a surgical admission, or a new blood thinner started after a heart procedure, matters to every doctor who prescribes for you. Keep the original with your records and hand out copies, so the document that explains the change is never lost with a single appointment.

A checklist before you leave hospital

Ask for a copy for yourself, keep it with your records, and bring it to your next appointment. If the summary is lost, the hospital’s medical records department can usually provide a copy on request.

• Your name, age and hospital number are correct.
• Any allergy you have is recorded.
• Every discharge medicine has a clear dose, frequency and duration, and stopped medicines are listed.
• You know the date and place of your follow-up appointment.
• Pending results are named, with who will act on them.
• You have a phone number to call if you have a problem after going home.

A note on this guide

Discharge summaries differ between hospitals, and not every summary contains every section described here. This guide is general information, not medical advice. Questions about your own treatment should go to the team that cared for you or to your doctor.