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What to write in a nursing facility discharge note? How to create a Discharge Note?

A nursing discharge note is an essential part of the patient's medical record and serves as a communication tool between healthcare providers. It should provide a clear and concise summary of the patient's condition, care, and instructions for ongoing treatment. Here are some important elements to include in a nursing discharge note:

Patient Information:

Full name, age, and medical record number.
Date of admission and discharge.
Contact information, if necessary.

Reason for Admission:

Explain why the patient was admitted to the healthcare facility.

Medical History:

A brief summary of the patient's relevant medical history and any chronic conditions.

Presenting Symptoms:

Describe the symptoms or conditions that led to the admission.

Care and Treatment:

Detail the care provided during the patient's stay, including medications, treatments, surgeries, or interventions.

Vital Signs:

Record the patient's vital signs, such as blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation, during their stay.

Laboratory and Diagnostic Tests:

Mention any relevant test results, such as blood tests, imaging studies, or other diagnostics.

Procedures:

Document any medical procedures performed during the admission.

Medication Information:

List all medications prescribed, including names, dosages, frequency, and any special instructions or changes made during the hospital stay.

Allergies:

Note any allergies or adverse reactions the patient has to medications or substances.

Nursing Assessments:

Include observations and assessments made by nursing staff during the patient's stay, such as wound care, pain assessment, and activities of daily living.

Patient Education:

Summarize any education provided to the patient and their family regarding post-discharge care, including medication management, dietary restrictions, wound care, and follow-up appointments.

Discharge Plan:

Outline the plan for the patient upon discharge, including medications to take at home, follow-up appointments, dietary restrictions, activity restrictions, and any necessary medical equipment or supplies.

Physician Orders:

Document any specific orders from the attending physician that pertain to the patient's discharge.

Follow-up Instructions:

Provide the patient and family with clear and concise instructions on what to do after leaving the healthcare facility. Include contact information for any questions or concerns.

Signature and Title:

The note should be signed by the responsible nurse, including their name and title, and may require the nurse's license number.
Any special considerations or concerns:

We provide this standardized Discharge Note template with text and formatting as a starting point to help professionalize the way you are working. Our private, business and legal document templates are regularly screened by professionals. Mention any unique circumstances or specific issues that need to be addressed post-discharge.

The nursing discharge note should be accurate, legible, and free from errors. It plays a critical role in ensuring a smooth transition of care for the patient and promotes patient safety. Additionally, it facilitates continuity of care by providing the necessary information for other healthcare providers who will be involved in the patient's ongoing treatment.

If time or quality is of the essence, this ready-made template can help you to save time and to focus on the topics that really matter! Using this discharge note template guarantees you will save time, cost and effort! It comes in PDF format, is ready to be tailored to your personal needs.

Download this Discharge Note template now for your own benefit!

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Discharge Note

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