University Health Network Discharge Summary Template for Dictation
www.uhnmodules.ca/DischargeSummary/guides.html March 2016
UHN Discharge Summary Template
Your dictated Discharge Summary should follow the template below. Include headings as they are appropriate:
1. Patient (Demographics)
Patient's hospital Medical Record Number (MRN)
Patient’s Date of Discharge
Diagnosis most responsible for the patient's course in hospital. If there is more
than one such condition, the one held most responsible for the greatest portion
of the length of stay or greatest use of resources
Location where the patient was discharged to. e.g. Home, Home with Support
Services, Transfer to Other Institution (named) or Death
Pre-existing / Developed
Conditions Impacting Hospital
Stay
Patient condition(s) that coexist at the time of admission or developed post-
admission and:
• Requires treatment, or
• Increases the length of stay by at least 24 hours (regardless of whether they
were managed intensively during the stay, e.g. dementia), or
• Significantly affects the treatment received
Conditions Not Impacting LOS
Pre-existing comorbidities or condition(s) that developed post-admission that
did not affect the patient's length of stay
4. Course While in Hospital
Symptom(s) for which the patient initially sought treatment and presented
with
Summary Course in Hospital
Succinct summary of the patient’s clinical course in hospital. Conclusion of
associated investigation
Succinct summary of examinations and tests conducted while in hospital
Procedure(s) and/or treatments(s) carried out during course in hospital
If available, list all relevant allergies and describe reaction
All Medications at Discharge
Home medications to be continued, home medications which have been
adjusted or discontinued, and newly prescribed medications
Follow-up Instructions for
Patient
Follow-up instructions for patient, including follow-up scheduled
appointments, if applicable
Follow-Up Plan Recommended
for Receiving Provider(s)
Investigations and interventions recommended to be conducted by the
receiving provider after the patient has been discharged
Referrals that have been initiated by the sender
Clinicians other than Primary Care/Referring Provider