When a patient is discharged from a hospital, a discharge summary or clinical résumé to document the care provided to the patient during his or her inpatient hospitalisation is prepared by any qualified individual such as the patient’s physician, a house medical officer, or a clerk.

This discharge summary placed in the patient’s record provides information for continuity of care and facilitates a medical staff committee review and it can also be used to respond to requests from authorised individuals or agencies (e.g., a copy of the discharge summary will suffice instead of the entire patient record).

10 contents of a discharge summary documents the patient’s hospitalisation which includes:

1. the reason(s) for admission
2. significant physical and other findings(e.g. brief clinical statement of chief complaint and history of present illness)
3. significant diagnoses and co-morbidities(example, Principal diagnosis: Cellulitis and gangrene, left foot and lower leg. Comorbidities: Diabetes mellitus, insulin dependent, controlled. Staphylococcus aureus coagulase positive septicemia. Urinary retention)
4. diagnostic and therapeutic procedures(example, Principal procedure: Amputation, left leg, above knee. Secondary procedures: Suprapubic cystostomy with permanent suprapubic drainage)
5. significant medication and treatments(medical and surgical) and patient’s response to treatment, including any complications and consultations
6. patient’s condition/status at discharge
7. discharge medications and all medications to be taken at home
8. follow-up instructions(patient education when applicable), to patient and/or family (relative to physical activity, medication, diet, and follow-up care)  including instructions for self-care, and that the patient/responsible party demonstrated an understanding of the self-care regimen
9. unless contrary to policy, laws, or culture, patients are given a copy
10. a copy is provided to the practitioner responsible for patient’s continuing or follow-up care

I am sure your hospital policy and procedures defines when a discharge summary must be completed, and that it must be placed in the record.

Such a policy and procedures are affirmed by the Joint Commission International(JCI) standard ACC.3.2 which states that “the clinical records of inpatients contain a copy of the discharge summary” and requires that a discharge summary must be prepared at discharge by a qualified individual, it contains follow-up instructions, that a copy  is placed in the patient record, the patient is given a copy of the discharge summary unless not allowed by hospital policy, laws, or culture, and a copy of the discharge summary is provided to the practitioner responsible for the patient’s continuing or follow-up care.

JCI Standard ACC.3.2 is expanded by JCI Standard ACC.3.2.1 which further qualifies the contents of a complete discharge summary.

The above 10 facts listed above covers all that is required by the 6 MEs of ACC.3.2 and the 6 MEs of ACC.3.2.1, when the discharge summary placed in a medical record is reviewed during a Medical Records Review.

Note : In Malaysia, the patient’s physician or a senior medical officer but NEVER a clerk, is responsible to prepare the discharge summary.