Writing notes and discharge summaries
Write so the next doctor can act without asking you. Date, time, findings, plan, your name. Discharge summaries need diagnosis, drugs, follow-up and red flags in plain language.
On this page
Progress notes
Use a simple format:
- Date and time.
- S: how the patient feels, new symptoms.
- O: observations, examination, new results.
- A: your assessment.
- P: the plan.
- Name, designation, signature.
On-call entries
- Who called you, when and why.
- What you found.
- What you did and why.
- Who you discussed it with.
- The plan and when it should be reviewed.
Discharge summaries
Include:
- Diagnosis and key events.
- Important results.
- Discharge medicines: name, dose, frequency, duration; highlight changes.
- Follow-up: when, where and with what tests.
- Red flags: when to come back, written in Urdu for the family.
Use the printable templates on this site.
Frequently asked questions
What should be in a discharge summary?
Diagnosis, key results, discharge medicines with changes highlighted, follow-up plans and red flags in plain language.