Discharge Summary

Finished note

Example — generated by Notat from a sample visit

Reason for visit:
Follow-up for a persistent cough and reduced energy over the past 10 days.

Assessment:
Symptoms are improving. No red flags identified during today's review.

Plan:
Continue supportive care, review worsening symptoms, and follow up if symptoms do not settle as expected.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

<b>Discharge Summary</b>

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

<b>Chief Complaint:</b> [Chief complaint or symptoms at time of presentation]
Date of Admission: [Admission date]
Date of Discharge: [Discharge date]

<b>Discharge Diagnosis:</b>
(hyphenated list)
#) (List as a numbered list if multiple diagnoses are provided)

<b>Summary of Clinical Course:</b>
(Structure course in hospital into detailed distinct paragraphs. Each paragraph should be a separate active issue. Summarize the patient’s key diagnostic findings, treatment administered, other specialities involved, and status at discharge. Use full sentences and formal clinical language.)

<b>Investigations:</b>
(hyphenated list)
- [Investigation results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

<b>Discharge Medications:</b>
(Hyphenated list)
- [Medication name, dose, route, frequency if mentioned]
- (e.g., Metformin 500 mg oral BID)

<b>Discharge Plan:</b>
(Use medical terminology if appropriate. Do not fabricate)

[One-sentence summary including age, sex, discharge diagnosis]
- [Discharge instructions]
- [Follow up plan]
- [Any pending results]
- [Home care or community support plans]