A handover body for the episode, discharge medicines, changes, pending results and actions that need to continue after discharge or transfer. Add patient identifiers, receiving-service details and author information separately.
How to fill it in
- Copy the blank template into your record system.
- Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
- Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.
Principal diagnosis
Record the responsible clinician’s stated principal diagnosis and its certainty. Distinguish confirmed, provisional and not established. Do not derive the principal diagnosis from the procedure name or a billing code.
Other diagnoses and problems
Record other established problems relevant to this episode, including unresolved issues. Distinguish active problems from background history and complications actually documented. Avoid turning every item in an old problem list into an active discharge diagnosis.
Episode summary
Describe the reason for admission, significant course and discharge status as established in the source record. Use relevant dates and a clear sequence. “Improved”, “stable” and “resolved” require the clinician’s actual assessment rather than an assumption from discharge occurring.
Procedures and investigations
Record procedures performed and investigations with their known dates, findings and status. Distinguish completed, attempted, cancelled and pending. Separate results available during admission from results that still require review.
Discharge medications
Record the authorised discharge list and its source. Preserve established names, strengths, formulations, doses, routes, frequencies and durations. A medicine used during admission does not automatically belong on the discharge list; a missing instruction remains missing.
Allergies and adverse drug reactions
Record known substances, reactions and their evidence or uncertainty. Retain an unresolved reaction history as unresolved. “No known allergy” must not replace a history that was not obtained.
Changes to medications
Describe medicines explicitly started, stopped or changed and the stated reason when available. Distinguish an implemented change from a recommendation awaiting review. Preserve the link to the discharge list rather than inferring a change from two incomplete lists.
Follow-up actions
Record requested or booked follow-up, the responsible service or person and stated timing. Identify an action awaiting allocation or acceptance. Discharge does not itself prove that the receiving clinician accepted an outstanding task.
Pending results
Identify each investigation awaiting a result, its known status and the stated reviewer or communication responsibility. Separate “not yet resulted” from “result not available in this record”. Do not guess a normal result or assign an unstated owner.
Record information and instructions actually given, who received them and the format when known. Include documented understanding or unanswered questions when elicited. Do not add restrictions, medicine instructions or warning symptoms from a standard postoperative routine.
Common omissions
Outstanding results, responsibility for review, reasons for medicine changes and the difference between requested and booked follow-up often disappear in a compressed episode summary.
Review before sending
Compare the discharge list with the recorded changes and confirm that pending results remain visible. Check that each follow-up action has its established status and responsibility, and that patient information reflects what was actually communicated. Apply local discharge and handover requirements.
Free to copy and adapt this template and guide, including for use in your practice. Sources linked above retain their own terms.
Use this guide to help write the record. It provides no clinical advice. The clinician remains responsible for checking that the record is accurate and complete. Check Medicare requirements, statutory forms and local policies separately.