A discharge summary includes which of the following?

• A. A comprehensive outline of the patient’s entire hospital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and patient’s response, final diagnosis, and follow-up plans
• B. A record of only medications prescribed at discharge
• C. A chart of vital signs
• D. A folder of lab results only

Answer: (A)

Discharge summaries are meant to be the complete, concise record of a patient’s hospital stay that guides ongoing care. They should tell the story from admission to discharge in a way that other clinicians and the patient can understand later. The best answer includes the patient’s condition at admission, the admitting diagnosis, the major tests and their results that guided care, the treatments given and how the patient responded, the final diagnosis, and clear follow-up plans. This bundle of information ensures continuity of care and helps the next clinician know why decisions were made and what to do next.

A record that lists only medications at discharge misses the why and how of the entire stay and how those meds fit into the overall course. A chart of vital signs or a folder of lab results by itself doesn’t provide the narrative of the hospital course or the planned follow-up, so it isn’t sufficient as the discharge summary.