Generate complete hospital discharge summary
AI asks about hospital course and treatment, then writes a comprehensive discharge summary ready for the medical record.
Generate complete hospital discharge summary
River's Discharge Summary Generator creates complete, professional hospital discharge summaries from patient hospitalization information. You provide admission diagnosis, hospital course, procedures performed, discharge diagnosis, medications, and follow-up plans, and the AI writes a comprehensive discharge summary in proper format. The summary includes all required elements for continuity of care, clear communication to outpatient providers, and medical record completeness. Perfect for attending physicians, residents, and hospitalists managing patient discharges.
Unlike rushing through discharge summaries at end of shift, this AI structures hospitalization information into properly formatted summaries. The tool systematically captures hospital course, significant events, test results, consultations, procedures, discharge condition, medications, and follow-up instructions. The summary communicates essential information to primary care providers and specialists continuing patient care. You focus on patient care and discharge planning, then let the AI create comprehensive summary that meets documentation standards.
This tool is perfect for hospitalists managing multiple discharges, residents writing discharge summaries after long shifts, attending physicians ensuring complete handoff documentation, or nurses coordinating discharge planning. If discharge documentation takes too long or summaries are incomplete, this creates professional, thorough discharge summaries efficiently. Use it for any inpatient discharge requiring comprehensive summary for medical record and outpatient provider communication.
What Discharge Summaries Must Include
Effective discharge summaries serve as critical handoff documents between inpatient and outpatient care. They must communicate why patient was admitted, what happened during hospitalization, what was done, final diagnoses, discharge condition, medications, and what needs to happen next. Weak discharge summaries are vague about hospital course, omit important test results or procedures, or lack clear follow-up plans. Strong summaries tell complete story of hospitalization so any provider can understand what happened and continue appropriate care. The summary is often the only communication outpatient providers receive about hospitalization.
Complete discharge summaries include specific required elements: admission date and reason, principal and secondary diagnoses, hospital course narrative, significant findings and procedures, discharge medications with changes highlighted, discharge condition and functional status, follow-up appointments and pending studies, and patient instructions. For complex hospitalizations, organize course by problem or system. Include consultant recommendations and pending test results that need outpatient follow-up. The summary should be detailed enough for billing and quality review while readable enough for busy outpatient providers to quickly understand key points.
Discharge summaries have legal and quality implications. They document medical decision-making during hospitalization, support diagnosis codes for billing, and provide evidence of appropriate care for quality measures and potential legal review. Include complications and how they were managed. Document patient education about diagnosis, medications, and warning signs. Clear discharge instructions reduce readmissions. Make sure medication reconciliation is accurate, especially changes from pre-admission medications. The discharge summary protects you legally and ensures patient safety through care transitions.
What You Get
Complete discharge summary with all required sections
Clear hospital course narrative organized by problem
Comprehensive medication reconciliation with changes noted
Discharge diagnoses with supporting documentation
Follow-up plan with specific appointments and studies
Professional format ready for medical record
How It Works
- 1Provide hospitalization detailsAI asks about admission reason, hospital course, procedures, and discharge plan
- 2AI writes summaryGenerates complete discharge summary in 10-15 minutes
- 3Review and finalizeVerify accuracy, add specific details, ensure completeness
- 4Add to medical recordComplete in EHR and send to outpatient providers
Frequently Asked Questions
Does this meet regulatory requirements for discharge summaries?
The AI creates discharge summaries with all standard required elements (admission/discharge dates, diagnoses, procedures, hospital course, medications, follow-up). However, ensure the final summary meets your institution's specific requirements and regulatory standards (Joint Commission, CMS). Review for completeness and accuracy. The AI provides comprehensive foundation, but you're responsible for ensuring all required elements are present and accurate for your facility's compliance needs.
Can I use this for observation stays or short hospitalizations?
Yes. For shorter stays, the hospital course will be briefer but structure remains the same. For observation stays, clarify it's observation status and document reasons for admission and discharge. For same-day procedures or short stays, the AI adapts to create appropriate length summary. Even brief hospitalizations need proper discharge documentation for continuity of care and billing.
How detailed should the hospital course be?
Include significant events, clinical decision-making, consultant input, major test results, procedures, complications, and response to treatment. Organize by problem for complex patients. You don't need to narrate every day, but capture key turning points, important findings, and reasoning behind major decisions. Include enough detail that quality reviewers can understand care provided and outpatient providers can continue appropriate treatment. For very complex or long hospitalizations, consider problem-based organization rather than chronological.
What about pending studies or test results?
Explicitly list any pending studies (labs, pathology, imaging) that need outpatient follow-up. State who will follow up on results and how patient will be notified. This is critical for patient safety and preventing lost results. If cultures are pending, note this and plan for contact if positive. If biopsy results will take days, document follow-up plan. Clear communication about pending results prevents gaps in care and ensures appropriate action on findings.
Should I send the discharge summary to the primary care doctor?
Yes. Most hospitals automatically send discharge summaries to listed primary care providers and specialists involved in care. However, for critical findings or urgent follow-up needs, consider additional communication (phone call, fax, or secure message). The discharge summary may not reach outpatient provider immediately. For urgent follow-up, direct communication ensures timely action. Document in summary that you contacted outpatient provider about urgent issues.
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