Medical discharge

See side note below

Summary:

Name is a blank-year-old lady who presented to the Emergency Department of Birmingham Heartlands Hospital on DATE with (symptoms). The history and clinical examination were in keeping with xxx. She was admitted for observation and supportive care. [More deets.] As she is now clinically stable, we are discharging her.

Name is a blank-year-old gentleman who presented to the Emergency Department of Birmingham Heartlands Hospital on DATE with (symptoms). The history and clinical examination were in keeping with xxx. He was admitted for observation and supportive care. [More deets.] As he is now clinically stable, we are discharging him.

Disclaimers to add at end of discharge letters

Kindly note that this discharge summary has been prepared based on documentation by my colleagues; this doctor has not been personally involved in the management of this patient.

Kindly note that this discharge summary has been prepared by a colleague; this doctor has not been personally involved in the management of this patient.

Information given to patients:

Please go to your nearest A&E should you become unwell after your discharge (e.g. if you experience uncontrollable pain, if you develop a high fever, etc).

Information given to GP:

Dear colleague, kindly note the recent admission of this patient.

** Note any medication changes in this section as well.

Side note: The more I do discharge letters, the less often I write them in paragraphs unless there are complex issues which require elaboration and nuance.

An example of how I write discharge letters nowadays is as follows:

66F
Admitted 03/02/2025 with fever, cough, and shortness of breath.

1. CAP
- CXR showed RUL consolidation
- CURB65 score = 2 (raised urea and age)
- Treated with co-amoxiclav 7 day course
- Repeat CXR requested for 6 weeks’ time to ensure resolution

2. Pre-renal AKI secondary to dehydration
- Resolved with IV fluids and oral rehydration