Discharge Summary Template with Canadian Examples

What is a Discharge Summary Template?

A discharge summary template helps doctors effectively document a patient’s hospital stay, including diagnosis, treatments, significant events, and follow-up instructions for their family physicians.

It serves as a clinical handover tool for your care team to ensure continuity of care and proper management of the patient's health after leaving the hospital.

This article walks through the benefits of using a template, its essential components, steps on writing a discharge summary (with examples), and templates you can use.

Advantages of Using a Template for Discharge Summaries

Freewriting discharge summaries often lack key details or become overly lengthy. The best way to avoid these pitfalls is by using a structured template for discharge summaries to ensure efficiency and consistency.

Here are six ways a discharge summary template can improve your documentation:

Reduces After-Shift Documentation Fatigue

A well-structured template provides pre-filled sections and standardised fields, so doctors and nurses aren’t starting from scratch every time. This prevents decision fatigue, speeds up completion, and reduces the need to stay later than needed to complete summaries after an exhausting shift.

Improves Continuity of Care

Standardised fields ensure that all critical details (e.g., diagnosis, treatments, and follow-up plans) are consistently documented. This minimises the risk of missing essential information when transitioning care to family physicians and community teams. Missing information can reduce the quality of follow-up care a patient receives in the community.

Prevents Medication Errors and Follow-Up Gaps

Missing or unclear discharge summaries can lead to incorrect prescriptions, untracked pending test results, and preventable readmissions. A structured format ensures that medication adjustments, allergies, and pending labs are clearly documented, preventing serious errors and potential patient harm from occurring.

Simplifies Compliance with Legal and Medical Standards

A template helps meet national guidelines and hospital policies by ensuring summaries contain the necessary clinical and administrative information. This reduces the risk of medico-legal issues and ensures your documentation is audit-ready.

Two standards show why this matters in practice: turnaround time and medication accuracy. Many hospitals and provincial standards give care teams about 48 hours to complete the discharge summary and get it to the primary care provider.

Medication reconciliation is central to that transition: teams compare discharge medications against the Best Possible Medication History (BPMH), catching discrepancies before they become someone's problem at home, and supporting safe follow-up on the other side.

Supports More Effective Multidisciplinary Collaboration

Discharge summaries and other critical records that need input from multiple healthcare teams can quickly become disorganised, leading to miscommunication, follow-up gaps, and added administrative burden.

The Cambridge North Dumfries Ontario Health Team (CND OHT) understood this challenge well. Spanning 40-plus agencies and supporting over 2,900 patient visits each week, the network ran a formal evaluation of Heidi across 169 clinicians before committing to a regional rollout.

The results were concrete. Clinicians saved an average of 11 minutes per visit, adding up to 530-plus hours supported each week across the team. With less time spent on documentation, 100% of clinicians reported feeling more present with their patients.

That shift showed up in how care was delivered, too. As Dr. Cameila Singh, Primary Care Lead at CND OHT, put it: “Not having to focus on notetaking, I can engage more with my patients, listen to their concerns, ask thoughtful questions, and develop more personalized and effective care plans.”

For a network this size, consistency across records mattered just as much as individual time supported. Eighty per cent of notes required minimal edits, and 70% of clinicians cited greater accuracy and clarity in their clinical records.

What to Include in a Discharge Summary Template

Many healthcare providers, from doctors to nurses, report challenges in effectively writing and receiving discharge summaries, often chasing missing details and working overtime to complete them. Incomplete or unclear summaries can lead to harmful medication errors, delayed follow-ups, and fragmented patient care.

A well-structured discharge summary should be concise, clinically relevant, and actionable, supporting a safe transition from hospital to outpatient care. Here are the 10 elements to include when writing discharge summaries:

1. Patient Information

This details the patient’s full name, date of birth, medical record number (MRN) or equivalent, and contact details to ensure accurate identification and prevent administrative errors. Include sex, gender, and address where required for compliance.

2. Healthcare Details, including Admission and Discharge Dates

This contains the hospital name, unit or ward, local health district (if applicable), and attending physician. Also include admission and discharge dates to provide clear context on the length of hospital stay and treatment timeframe.

3. Primary Diagnosis with Secondary Diagnoses and Comorbidities

This includes the main reason for admission, ensuring family physicians and community teams understand the core issue (or issues) requiring follow-up. Any pre-existing or newly diagnosed conditions that might impact ongoing care and medication management should be present as well.

4. Summary of Hospital Stay

This is a brief timeline of key interventions, procedures and treatments provided, significant investigations, and notable clinical events, avoiding unnecessary details. If the patient spent time in ICU or required high-dependency care, provide a brief summary of their stay and progression.

5. Medication List

Clearly categorize medications on discharge into:

• New medications (started during admission)
• Changed medications (adjusted dosage or formulation)
• Unchanged medications (continued from prior regimen)
• Ceased medications (ceased during admission)

Include dose, route, frequency, duration, and indication for each drug. Ceased or temporarily suspended medications must be listed with reasons for discontinuation. Further, list all surgeries, interventional procedures, and key medical treatments performed during admission.

6. Allergies and Other Special Considerations

Document medication, food, or environmental allergies with a clear reaction type (e.g., anaphylaxis, rash). If the patient has no known allergies, state “Nil known” explicitly to prevent uncertainty.

Any infection risks, fall risks, anticoagulation therapy, or cognitive impairments requiring special handling should also be clearly indicated.

7. Follow-up Plans and Pending Results

Specify who is responsible for each follow-up action (e.g., family medicine, specialist, allied health) and flag pending investigations with instructions on the next steps. Additionally, scheduled follow-up appointments should include date, time, location, and provider details.

8. Patient Advice and Self-Care Instructions

Provide plain-language guidance on diet, mobility, wound care, medication adherence, and red-flag symptoms that need urgent medical attention. Where possible, use patient-friendly formats and avoid medical jargon for clarity.

Different Formats of a Discharge Summary Template

Discharge summary template formats differ by hospital and EMR systems, but they all aim to give a clear and concise overview of a patient's hospital stay and follow-up care needs. Here are the most common formats:

1. Narrative Format

This discharge template format is a free-text, paragraph-style summary that provides a chronological account of the patient’s hospital stay, including admission, key events, treatments, and discharge plans.

The narrative format for discharge summaries is ideal for complex cases that require detailed context (e.g., multi-organ failure, prolonged ICU stays) but it can also become too lengthy and difficult to scan, making it harder for outpatient providers to find key details quickly.

2. Bullet Point Format

This discharge template format presents patient information in a structured, itemized list, making it easy to scan. It highlights key aspects of the hospital stay, including admission details, primary diagnosis, major interventions, and discharge instructions in a concise manner.

Using bullet points in discharge summaries is especially useful for straightforward cases with clear diagnoses and treatments (e.g., routine surgeries, short hospital stays). However, it may lack the nuanced clinical context needed for complex cases, making it harder to understand the full narrative of the patient’s hospital course.

3. Problem-Based Format

This format organises information under each active medical problem addressed during hospitalisation.

The problem-based approach works best for patients with multiple comorbidities requiring detailed, condition-specific follow-up care. In some instances, it may not provide a fluid summary of the hospital course, making it harder to grasp the overall treatment timeline.

Tips to Write a Good Discharge Summary

Having a well-formatted template for discharge summaries containing the crucial details is a good start, but effective documentation goes beyond structure.

Here are some practical tips for writing a discharge summary that genuinely serves everyone who reads it:

Keep it concise but informative.

A discharge summary should be clear, direct, and clinically useful with all salient details from an admission included. While it doesn’t need to be a novel, it should provide enough detail for outpatient providers and future hospital teams to understand the admission, necessary follow-ups, and provide a holistic view of a patient’s medical history.

Start early for complex cases.

If a patient has a prolonged or complicated hospital stay, begin drafting the summary as early as day 2 or 3. This avoids last-minute rushing and ensures key details are accurately noted while still fresh.

Summarize, don’t narrate.

Avoid a day-by-day play-by-play of every event during admission. Focus on major clinical decisions, key investigations, and any changes in management that impact ongoing care.

Consider your audience beyond hospital staff.

Your summary isn’t just for other residents or specialists; it gets faxed to family physicians, nurses, pharmacists, and other health professionals, many of whom don’t use the same shorthand. Avoid excessive abbreviations to prevent confusion and misinterpretation of instructions.

Be mindful of patient readability.

Patients and their families may access the discharge summary, so choose your wording carefully. Avoid overly technical or judgmental language (e.g., "non-compliant patient"), and instead use objective, professional descriptions that maintain trust and clarity.

Discharge Summary Examples

A well-written discharge summary provides clear, concise, and actionable information to GPs, nurses, and other healthcare providers. Below are two specific examples tailored to different use cases:

1. General Hospital Discharge Summary Example

Patient & Hospital Details

• Patient Name: John Doe
• Date of Birth: 12-Jun-1952 (Age: 72)
• Medical Record Number (MRN): [123456]
• Health Card Number (HCN): [1234-567-890-XX]
• Date of Admission: 10-Jan-2025
• Date of Discharge: 15-Jan-2025
• Facility/Unit: City General Hospital – Respirology / General Internal Medicine (GIM)
• Most Responsible Physician (MRP): Dr. James Patterson, MD, FRCPC
• Primary Care Provider (PCP): Dr. Sarah Mitchell (Family Physician, Riverside Family Health Team)

Diagnoses

• Most Responsible Diagnosis (MRDx): Community-Acquired Pneumonia (CAP) requiring supplemental oxygen therapy (Resolved)
• Secondary / Comorbid Diagnoses:
  • Hypertension
  • Type 2 Diabetes Mellitus
  • Chronic Kidney Disease (CKD Stage 3)

Specialist Consultations & Procedures

• Specialist Consultations:
  • Infectious Diseases: Consulted for guidance on empiric antibiotic coverage, step-down oral options, and treatment duration in the setting of CKD.
  • Respirology: Consulted for management of persistent hypoxemia and oxygen weaning protocols.
• Operative & Invasive Procedures: None

Course in Hospital

History of Present Illness (HPI)

A 72-year-old male presented to the Emergency Department with a 3-day history of worsening dyspnoea, productive cough, and fevers. Chest X-ray (CXR) on presentation demonstrated right lower lobe (RLL) consolidation, consistent with CAP. Empiric therapy was initiated with IV ceftriaxone and IV azithromycin. Required supplemental O2​ via nasal cannula at 2 L/min to maintain target oxygen saturations (SpO2​>92%).

Clinical Progress & Management

• Infectious Disease Response: The patient demonstrated gradual clinical and symptomatic improvement on empiric parenteral antimicrobial therapy. Fever resolved by Hospital Day 3.
• Diagnostic Imaging: Repeat CXR on Hospital Day 4 showed resolving right lower lobe infiltrates.
• Respiratory Status: Oxygen was successfully weaned; patient remained stable on room air by Day 5.
• Microbiology: Blood cultures (2 sets drawn on admission) showed no growth to date.
• Medication Step-Down: Transitioned to oral levofloxacin 750 mg PO daily on Day 6 to complete a total 10-day course.

Special Considerations & Alerts

• CKD Stage 3: Avoid nephrotoxic agents (e.g., NSAIDs, iodinated contrast). Monitor eGFR and serum creatinine.
• Type 2 Diabetes: Monitor for transient glycemic dysregulation secondary to recent infection recovery.

Discharge Medications (BPMH)

• Levofloxacin 750 mg PO daily – Continue for 5 more days (Last dose: 20-Jan-2025)
• Lisinopril 10 mg PO daily – Resumed baseline home dose
• Metformin 500 mg PO BID – Continued baseline home dose

Discharge Plan & Instructions

Discharge Disposition: Discharged Home with family support. Self-monitoring.

Dietary Recommendations: Diabetic, low-sodium diet; maintain adequate hydration.

Instructions to Patient:

• Red Flag Symptoms: Seek immediate emergency medical care (return to Emergency Department) for high fevers, worsening shortness of breath, pleuritic chest pain, or confusion.
• Advised to complete the full course of oral antibiotics as prescribed.
• Pacing and gradual resumption of activities over the next 2 weeks; avoid strenuous physical exertion.

Post-Discharge Follow-Up:

• Family Physician: Dr. Sarah Mitchell, Riverside Family Health Team – Appointment scheduled for 20-Jan-2025 (Medication reconciliation and post-discharge evaluation).
• Respirology Clinic: Dr. Anne Roberts, City Hospital Respirology Outpatient Clinic – Requested within 4–6 weeks for follow-up CXR and clinical review.

Copies Sent To:

• Dr. Sarah Mitchell (Family Physician)
• Patient / Family

2. Behavioural Health Discharge Summary Example

Patient & Hospital Details

• Patient Name: Jane Doe
• Date of Birth: 15-Aug-1988 (Age: 36)
• Gender: Female
• Medical Record Number (MRN): 789654
• Health Card Number (HCN): [9876-543-210-XX]
• Date of Admission: 05-Dec-2024
• Date of Discharge: 12-Dec-2024
• Admission Legal Status: Voluntary (Mental Health Act Form 2 cleared in ED prior to admission)
• Facility / Unit: City Health Centre – Adult Inpatient Psychiatry Unit
• Most Responsible Physician (MRP): Dr. Lisa Carter, MD, FRCPC (Psychiatry)
• Outpatient Provider: Dr. Emily Henshaw, Willow Mental Health Clinic

Diagnoses (DSM-5-TR / ICD-10-CA)

• Most Responsible Diagnosis (MRDx): Major Depressive Disorder, Single Episode, Severe with Active Suicidal Ideation (Discharged in Partial Remission)
• Secondary Diagnoses & Comorbidities:
  • Generalized Anxiety Disorder
  • Alcohol Use Disorder (In sustained early remission)

Interprofessional Consultations & Therapeutic Interventions

• Interprofessional Consultations:
  • Psychology: Cognitive Behavioural Therapy (CBT) psychoeducation initiated.
  • Social Work: Discharge planning, community resource navigation, and outpatient mental health care alignment.
  • Occupational Therapy (OT): Functional assessment, routine building, and coping mechanism evaluation.
• Invasive Procedures / ECT:
  • None.

Course in Hospital & Clinical Progress

History of Present Illness (HPI):

A 36-year-old female presented voluntarily to the Emergency Department following family intervention due to worsening depressive symptoms, active suicidal ideation without explicit plan, and severe psychosocial stressors including recent job termination. Evaluated in ED and admitted under the care of Inpatient Psychiatry for safety, stabilization, and pharmacotherapy optimization.

Course in Hospital & Clinical Progress:

• Pharmacotherapy: Started on sertraline 50 mg PO daily for mood. Hydroxyzine 25 mg PO PRN (up to TID) was prescribed for acute anxiety management.
• Therapeutic Interventions: Actively participated in daily unit milieu activities, individual supportive psychotherapy, and group Dialectical Behaviour Therapy (DBT) skill-building modules (distress tolerance and mindfulness).
• Safety & Mental Status Examination (MSE): Expressed clear resolution of active suicidal ideation by Day 5. Mood stabilized noticeably; acknowledges ongoing vulnerability to stress and expressed commitment to outpatient treatment.

Safety Plan and Risk Management

• Suicide Risk Evaluation: Moderate baseline risk post-discharge. Safety plan co-created with patient and copy provided upon discharge.
• Substance Use: History of Alcohol Use Disorder (remission). Patient counseled on relapse prevention and maintaining abstinence.

Discharge Medications (BPMH)

• Sertraline 50 mg PO daily – 30 days supply + 2 refills
• Hydroxyzine 25 mg PO PRN (up to TID) – For acute anxiety

Discharge Plan & Community Follow-Up

• Discharge Disposition: Discharged Home with family support.
• Crisis Contact: Provided with 988 Suicide Crisis Helpline (Call/Text 24/7).
• Outpatient Psychiatrist: Dr. Emily Henshaw – 18-Dec-2024 at 10:00 AM.
• Psychotherapy: Willow Community Counselling Centre – 22-Dec-2024.

Copies Sent To: Dr. Emily Henshaw (Outpatient Psychiatrist), Family Physician

Free Discharge Summary Templates