Nursing Discharge Notes

What is a Nursing Discharge Note?

A Nursing Discharge Note is an essential document in the healthcare field. It is a comprehensive record summarizing a patient's hospital stay from admission to discharge and detailing their health status and treatment plans. Created by a qualified nurse, these notes are a critical component of the healthcare communication system, providing essential information for future care planning and enabling a seamless transition from hospital care to home or another healthcare facility.

The depth and breadth of information captured in a discharge nursing note make it an indispensable tool for patient care. It encapsulates many elements, including the patient's identification, the diagnoses made during the stay, the treatments administered, and the patient's condition at discharge. It also outlines the instructions for the patient's care after leaving the facility, medication details, and plans for any follow-up care.

Discharge nursing notes also help educate the patient and their family about their health condition, the importance of medication adherence, and any potential signs or symptoms that need to be monitored post-discharge. It is a roadmap for the patient's healthcare journey beyond the hospital, providing the necessary guidelines for continuous and effective care.

From a broader perspective, discharge nurses' notes aid in individual patient care and contribute to the more extensive healthcare system. They provide valuable data for research, help identify trends, and can be used to enhance patient care protocols and hospital discharge processes.

Despite being a single document, discharge nursing notes have a manifold and far-reaching impact, underlining their crucial role in successful patient recovery and overall healthcare management. Continue reading our guide, and you will see a discharge nursing note example.

How does it work?

Nursing Discharge Notes are a comprehensive record of a patient's hospital stay, their health status at discharge, and the care plan post-discharge. These notes ensure a seamless transition of care from the hospital to the home or another healthcare setting.

Step 1: Download the template

Download our discharge note nursing template by clicking on the link found in this guide. You can also use the discharge note nursing example. Our sample Nursing Discharge Note is a practical tool for your reference.

Step 2: Fill out patient information

This initial step involves recording the patient's demographic information, including name, age, gender, and identification number. Additionally, the dates of the patient's admission and discharge are included.

Step 3: Write down the diagnosis and treatment

The healthcare professional will then note the initial diagnosis that led to the patient's hospital admission. They are also documented if other diagnoses were made during the hospital stay. Lastly, the final diagnosis at discharge is recorded. You should also enumerate the various treatments that the patient received during their hospital stay. This can include surgical procedures, medications, therapies, and other interventions.

Step 4: Indicate the patient's condition at discharge

This step involves documenting the patient's health status at the time of discharge. Vital signs, physical conditions, mental status, and any remaining health issues are typically recorded.

Step 5: Note discharge instructions

Written discharge instructions are helpful for the patient to follow after discharge. These can include medication instructions, diet, activity levels, necessary follow-up appointments, and specific signs or symptoms that should prompt a call to the doctor.

Step 6: Provide a list of medications

An accurate and updated list of medications is provided. This list includes medications the patient was taking before admission, any changes made during the hospital stay, and what the patient should continue taking post-discharge.

Step 7: Plan for patient education and follow-up care

This section details the education or information provided to the patient and their family. Topics can include medication management, wound care, dietary restrictions, or the use of medical equipment at home. Also, don't forget to record any planned follow-up care. This could include referrals to specialists, scheduled tests, ongoing therapies, or appointments. See our Nursing Discharge Note example to check what discharge documentation could look like.

When would you use this template?

The Nursing Discharge Note template is not only for those in hospital settings but also applies across healthcare services. Here are some instances when the use of a Nursing Discharge Note template is particularly appropriate:

Upon a patient's discharge from a hospital or healthcare facility

This is the most common scenario for using a Nursing Discharge Note. The note provides a comprehensive overview of the patient's stay, treatment, and condition at discharge, assisting in the transition to home care or another healthcare setting.

When transitioning a patient's care to another healthcare provider

Suppose a patient is being moved from one caregiver to another. In that case, a Nursing Discharge Note can provide the new provider with a complete picture of the patient's medical history, current condition, and treatment plan.

To inform a primary care physician about a patient's recent hospital stay

The primary care physician, who continues the patient's care after discharge, may need to gain direct knowledge of the hospital stay. In such cases, the Nursing Discharge Note provides useful information about the treatment, medication changes, and instructions for further care.

To provide a patient and their family with clear instructions for care post-discharge

Transitioning from hospital to home care can be challenging for patients and their families. The Nursing Discharge Note guides them in understanding the required care procedures, follow-up appointments, and when to seek medical help.

To document the patient's medical history and treatment for future reference

Over time, a patient's medical history can become extensive and complex. A Nursing Discharge Note concisely summarizes each hospital stay to help keep track of this history.

Benefits

A Nursing Discharge Note offers multiple benefits for the healthcare professionals who create and use them and the patients they serve. Its use is crucial in patient safety, care continuity, and communication among healthcare providers.

Clear communication

A well-written Nursing Discharge Note ensures effective communication among healthcare providers, patients, and their families. It provides a clear and complete account of the patient's hospital stay, which is crucial for ongoing care.

Continuity of care

The Nursing Discharge Note is pivotal in maintaining continuity of care. It provides a detailed summary of the patient's condition at discharge, instructions for further care, and a follow-up plan.

Legal documentation

In addition to its role in patient care, the Nursing Discharge Note also serves as a legal record of the patient's medical history, treatment provided, and condition at discharge. It is a critical document for any legal inquiries or audits.

Reduced readmissions

A Nursing Discharge Note that includes detailed and understandable discharge instructions can help reduce hospital readmissions. It ensures that the patient and their family know how to manage care post-discharge, which conditions or symptoms should prompt a call to the doctor, and when and where to go for follow-up appointments.

Patient safety

The Nursing Discharge Note is a critical tool for patient safety. It documents all pertinent information about a patient's condition, treatment, and plan for ongoing care. It helps prevent medical errors and misunderstandings that could compromise patient safety.