Discharge documentation
Discharge documentation is a safety-critical summary of the hospital episode that supports continuity between inpatient and outpatient care.
Open interactive lesson & self-check ↗Discharge documentation — specialty learning map
Original conceptual SVG · scalableOriginal overview diagram showing four related domains. This is not a literal anatomy drawing, histologic image or clinical decision rule.
Diagnosis and course
Record relevant confirmed or working diagnoses, important investigations, interventions and the response during admission using accurate, unambiguous language.
Medication reconciliation
Document intended medicines and important changes from the pre-admission regimen, ensuring that the responsible clinical team verifies the final list.
Follow-up and pending items
State necessary appointments, pending results, responsibility for action and relevant instructions in understandable language.
Communication and safety
Ensure the patient and receiving team know warning symptoms requiring assessment and can access the necessary information with appropriate consent.
Reference and next reading
Explore the original curriculum and publisher-hosted resources for full-depth reading; this note is an original schematic introduction, not an exhaustive chapter.