A discharge summary tells the next clinician what happened during an episode of care and what needs to happen now. Write it at the point of discharge, covering the presentation, diagnoses, a short clinical summary, medicines and allergies, recommended actions and booked follow-up, then send it to a confirmed recipient without delay.
Discharge is where care is most likely to fall through a gap. The receiving clinician was not in the room, cannot see your notes, and will act on whatever your summary says. This guide covers what to include under current Australian guidance, a worked example, and the mistakes that turn a summary into a risk.
What is a discharge summary?
A discharge summary is a curated clinical document that hands a patient from one care setting to the next. The Australian Commission on Safety and Quality in Health Care puts the purpose plainly: tell clinicians what happened to a patient in hospital and what is required after they leave. The usual recipient is the patient's general practitioner, but community providers, specialists, later treating teams, clinical coders and the patient and their carers all read it.
Two documents share the name. A hospital discharge summary closes an admission; a closure summary in private practice closes an episode of therapy. The guidance below applies to both, with the differences covered further down.
Why does the discharge summary matter more than most documents?
Because transitions of care are where harm concentrates. The Commission's national guidelines, revised in September 2025 from the 2017 edition, name discharge as a high-risk event and link incomplete summaries to medication errors, inadequate follow-up, avoidable readmissions and, at worst, patient deaths.
Communication at handover is also a regulated expectation, not just good manners. It sits inside the Communicating for Safety Standard in the National Safety and Quality Health Service Standards, which requires systems for correct, timely communication at transitions of care. For registered practitioners, the record carries its own obligations: the Psychology Board of Australia's code of conduct requires records that are accurate and sufficient for another practitioner to continue care. A vague discharge summary fails that test even when the clinical work behind it was excellent.
What should a discharge summary include?
The national guidelines describe an electronic discharge summary as a header plus a body, and specify what belongs in each. Use it as a checklist:
- Author details. Name, designation, and a contact number, near the service details so the recipient knows who to ring for clarification.
- Presentation details. Presentation and discharge dates, length of stay, ward or unit, episode type, the senior clinician responsible, and the discharge destination.
- Problems and diagnoses. Reason for presentation, principal diagnosis, secondary diagnoses, complications, and relevant past medical history.
- Recommendations. Actions required after discharge, each with a timeframe where relevant and the name of the person it is directed to.
- Clinical summary. A concise narrative of the episode: what was assessed, what was done, how the person responded.
- Allergies and adverse reactions. Both pre-existing and newly identified.
- Medicines on discharge, and ceased medicines. What the person is taking now, what stopped, and why it changed.
- Follow-up appointments. What is booked or recommended, with dates, booking status, the provider, the location and their contact details.
- Information provided to the patient. What the person and their carers were told and given.
Two structural points are easy to miss. First, the recommendations belong near the top, not at the end: the Commission moved them up after finding that long summaries pushed the most important content several screens down, a change supported by eye-tracking evidence about where readers actually look. Second, write so the patient can follow it, because patients and carers receive a copy too.
How do you write a discharge summary, step by step?
- Start it early, finish it at discharge. Draft during the episode and update as the picture changes. Summaries reconstructed days later from memory are where omissions come from.
- Write the recommendations first. Decide what the next clinician must actually do, then let the rest of the document support that.
- Reconcile the medicines deliberately. List current medicines, list what was ceased, and give the reason for every change. Unexplained changes are the most consequential ambiguity in a discharge summary.
- Curate, do not copy. Bulk-pasting from the record is a known failure mode: it imports errors and irrelevant detail, and buries the parts that matter.
- Spell out abbreviations. The guidelines advise avoiding abbreviations and jargon, and writing in full at first use any that must be kept.
- Confirm the recipient with the patient. Names, practices and preferred providers change. Confirm before you send, not after it bounces.
- Escalate beyond the document when the case warrants it. Recipients cannot acknowledge a summary in real time, so for complex or time-critical cases the guidelines recommend pairing it with a phone call or case conference. Then the clinician with authority to finalise attests to it, and it goes out.
What does a discharge summary look like?
A fictional example, from an inpatient mental-health admission back to a GP and community psychologist:
Note what the recommendations do: each is specific, addressed to a named person, and carries a timeframe. That is the difference between a summary that transfers responsibility and one that only describes a stay.
How is a private-practice closure summary different?
In private mental-health practice there is no admission to close, so the document does the same job for an episode of care: presenting concerns, formulation, interventions used, outcome measures at intake and ending, the reason for ending, and what the person should do if things deteriorate. The reason for ending matters more than clinicians expect: "goals met, agreed ending" and "disengaged after two sessions" carry very different risk for the next practitioner.
Writing back to the referring GP follows the same conventions as an effective referral letter in reverse: be specific, be brief, make the requested action obvious. The evidence base sits in your session documentation, so consistent mental health progress notes turn a closure summary into a half-hour task. For how the formats differ, start with what clinical notes are.
What are the most common discharge summary mistakes?
- Sending it late. A summary that arrives after the first follow-up appointment did not do its job.
- Copy-paste bloat. Length is not thoroughness. The receiving clinician has minutes, not hours.
- Unexplained medicine changes. Listing what someone takes without saying what changed, and why, invites errors.
- Recommendations with no owner and no timeframe. "Follow up as needed" allocates responsibility to nobody.
- Abbreviations only your unit uses. A recognised source of misinterpretation.
- Writing as if the patient will never read it. They receive a copy, so blunt shorthand lands badly.
- No safety-net advice. Say what deterioration looks like and exactly who to contact.
How do My Health Record and privacy obligations fit in?
A discharge summary is sent directly to the intended recipient, and where a hospital is connected to the national system a copy can also be uploaded to the patient's My Health Record, where it sits under clinical records for other treating providers to see.
Health information is sensitive information under the Privacy Act, so disclosure is governed by the Australian Privacy Principles, including the rules on use, disclosure and security. In practice: send to the confirmed recipient by a secure channel, include only what is relevant to ongoing care, and be deliberate about sensitive detail that may belong in another channel rather than this document.
Can software make discharge summaries faster?
Yes, if it removes retyping rather than adding a second place to type. The gains come from summaries that pull structured data you have already captured, templates that enforce the section order, and an audit trail of who finalised the document and when.
PractaLuma is AI-native practice management software for Australian mental-health practices, so session notes, outcome measures, referrals and correspondence live in one record and a closure summary can be drafted from the episode rather than assembled by hand. See the features page or pricing. Whatever drafts it, the clinician who signs it is accountable for its accuracy: review every line before it goes out.
Frequently asked questions
How long should a discharge summary be? Long enough to transfer the clinical picture and the required actions, and no longer. One to two pages is typical. The national guidelines favour concise, curated content and warn that long documents push critical information out of view.
When should a discharge summary be sent? At the point of discharge, and always before the first follow-up appointment. Draft it during the episode so finalising takes minutes.
What goes in the recommendations section? Actions needed after discharge that are not obvious elsewhere in the document: reviews, monitoring, tests, therapy continuation, each with a timeframe and a named person responsible. It is not a place to repeat the medicines list.
Is a therapy closure summary the same as a hospital discharge summary? Not identical, but the job is the same: describe the episode, state the outcome, name what happens next. A closure summary adds formulation, outcome measures at intake and ending, and the reason the episode ended.