Veterinary Discharge Summaries: What They Should Include and How to Write Them
A discharge summary summarizes a period of care in a single document. It is often written when an animal is discharged after a hospital stay or when a longer course of treatment is completed, and it allows the next reader to understand what has happened without having to go through every medical record entry.
What a discharge summary is
The medical records describe each visit or each day separately. The discharge summary ties them together into a narrative of the entire course of events, from the reason for the visit to the plan following discharge.
The discharge summary also differs from the discharge instructions. The discharge instructions are intended for the pet owner and describe what needs to be done at home, while the discharge summary summarizes the care provided for the person who will take over or follow up on the patient.
Who reads the discharge summary
The content and language depend on who will be reading the text. A referring veterinarian wants to know what was examined, what was found, and what needs to be followed up on. A colleague taking over the patient’s care also needs to know what treatment is currently being administered. The pet owner needs a version without abbreviations or technical terms—or advice for care at home instead of a discharge summary.
Therefore, write the discharge summary for the most important reader, and let the discharge instructions cover what the pet owner needs to know.
A discharge summary usually summarizes the following
A discharge summary is based on the information already in the medical record and typically includes the following:
- The reason for the visit or referral.
- What happened during the hospital stay, in the order it occurred.
- Studies Conducted and Their Results.
- The treatment that has been provided.
- The animal's condition at the time of discharge.
- The follow-up plan and who is responsible for it.
The discharge summary should not contain anything that is not in the medical record. If any information is missing when the discharge summary is written, it should be added to the medical record first.
The same information as in the medical record
Since the discharge summary summarizes the medical record, the two must be consistent. The information provided by the pet owner is kept separate from what the staff has observed and examined themselves, just as in a medical record written according to the SOAP format. How this separation works is described in the guide on SOAP medical records for veterinarians.
A discharge summary written in a hurry often ends up being a repetition of the medical record or omits important details. Both of these errors are common even in regular medical record entries, and more such errors are discussed in the article on the most common mistakes in medical record-keeping.
Discharge Summary or Discharge Instructions
When the animal goes home, the pet owner needs clear instructions, while the referring veterinarian needs a summary. These are two different texts intended for different audiences. Vetz generates personalized discharge instructions directly from the medical record, written in a way that the pet owner can understand. How this works is described in the article on discharge instructions.
Here's How AI Can Help
Writing the discharge summary takes time because it requires the veterinarian to review the entire course of treatment. Vetz creates structured draft medical records based on the conversation with the pet owner and follows the practice’s own templates, so that the clinic can have its own template for discharge summaries as well. Vetz can also improve, rephrase, or clarify a text—for example, when a discharge summary needs to be rewritten for a different reader.
The veterinarian always reviews and approves the text before it is sent. For more information about the workflow, see the guide on AI-powered medical record-keeping for veterinarians.
A Framework to Build Upon
A simple discharge summary template follows the timeline of the patient’s care. Begin with the reason for the visit or referral, then describe the course of the patient’s care, including examinations, results, and treatment, and conclude with the patient’s condition at discharge and the plan for follow-up. Using the same order in every discharge summary makes it easier for the recipient to find the information that pertains specifically to them.
Learn more about Vetz
Would you like to see how Vetz can help with medical records, discharge summaries, and discharge instructions? Schedule a demo, and we'll show you using your own templates.