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Discharge Summary From Hospital Notes
A discharge summary built from your own notes, with every medication change explained and every result still pending assigned to a named owner.
River's discharge summary writer turns the notes from an admission into the summary the next clinician actually reads. Paste the progress notes, the medication changes and whatever you jotted at discharge, shorthand included. Back comes a plain-text summary in the standard order, ready to paste into the record. It covers why the patient came in, what was found and done, the condition at discharge, every medication started, changed or stopped with its reason, and the follow-up. Nothing is added that your notes do not say.
Unlike the template sites that rank for this search, this does not stop at headings with blanks under them. A template cannot notice that a medication changed without a reason, or that a culture was still growing when the patient left. Those are the two gaps that hurt patients after discharge, so each gets its own section. Anything your notes leave unclear is marked in brackets for you to fill, rather than smoothed over with a plausible sentence you might sign without seeing.
This is for hospitalists, residents and nurse practitioners closing out admissions, and for anyone handing a patient to a skilled nursing facility by noon. You review, correct and sign it, and the clinical judgment stays yours. When a goals of care conversation shaped the plan, the family meeting note records what was decided. When the patient needs a specialist afterwards, a referral letter carries the clinical question forward. Records arriving from another hospital are easier to use once they are in an outside records chronology, so do that before you write.
The summary is the handoff, and it often arrives late
Federal rules set a floor, not a format. A hospital's record must include a discharge summary covering the outcome of hospitalization, the disposition of the case and provisions for follow-up care, alongside the final diagnosis. The discharge planning rule adds that the hospital sends the necessary medical information, including post-discharge goals of care and treatment preferences, to whoever provides the follow-up care. Everything else, from section order to length, is set by your institution and your medical staff.
The evidence on what goes missing is old and still uncomfortable. A systematic review in JAMA found the discharge summary available at the first follow-up visit in only 12 to 34 percent of cases. Test results pending at discharge were missing from 65 percent of the summaries that did exist, and medication information from up to 40 percent. Those two omissions are where a summary becomes a safety problem, because nobody downstream knows a result is coming or why a drug changed.
So write the medication section as a comparison, not a list. For each drug, say whether it was started, changed, stopped or continued, and give the reason in a few words, such as metoprolol succinate increased from 25 to 50 mg daily for rate control. Then list every pending result with the person who will follow it up and how the patient will hear. If the reason or the owner is not in your notes, leave the bracket in place and settle it before you sign.
How it works
Paste your notes
Progress notes, medication changes and your discharge jottings, shorthand and all, with identifiers removed if needed.
Pick the reader
Say who takes over care, so the summary leads with what that reader needs to act on.
Get the summary
A plain-text discharge summary in the standard order, with gaps marked in brackets for you to fill.
Check and sign
Ask for a shorter version, a patient copy or a different order, then review and sign it yourself.
What you get
- A complete discharge summary in the standard order, in plain text that pastes into the record
- Every medication marked started, changed, stopped or continued, with the reason for each change stated
- Results still pending at discharge listed with the person responsible for following each one up
- Your shorthand read correctly, so 72M, down 4 kg and cards in two weeks become full sentences
- Gaps marked in brackets for you to fill, never covered with a plausible sentence you did not write
- Detail shaped for whoever reads it first, from a primary care doctor to a nursing facility
Common questions
Can I paste real patient details?
Follow your organization's policy first. If your organization has a business associate agreement with River, work within its terms. If not, remove names, record numbers, addresses, exact dates and other identifiers before pasting, and describe timing as hospital days. The summary keeps placeholders such as [Patient name] and [Admission date] for you to fill inside your own record system.
Will it add findings my notes do not mention?
No. Every diagnosis, value, procedure and medication in the summary comes from what you pasted. Where a section needs something your notes do not contain, such as a discharge weight or a code status, it shows a bracketed gap instead of a likely value. That makes the gaps easy to spot and keeps the signed document an accurate record of the admission.
What if my hospital uses its own format?
Paste the headings or a de-identified example with your notes and the summary follows that order and style. Without one, it uses the common order: diagnoses, procedures, consultations, hospital course, condition at discharge, medications, instructions, follow-up and pending results. A problem-based hospital course works too, and is usually clearer for long or complicated stays.
How should pending results be handled?
Name each one, who will follow it up, and how the patient will be told. A culture with no owner is how a positive result gets missed after discharge. If your notes do not say who owns it, the summary leaves a bracket for you to fill. For a result that could change treatment urgently, call the receiving clinician as well.
Does it work for transfers to a nursing facility?
Yes, and that reader needs more than a primary care doctor does: function and mobility, diet, skin and wound care, lines, code status, the timing of the last dose of anything time-critical, and who to call with questions. Choose the nursing facility as the reader and those sections are filled from your notes or flagged where missing.
Is this the same as the patient's discharge instructions?
No. The discharge summary is written for clinicians, and patients need instructions in plain words at a reading level they can use. Ask for a patient copy once the summary is done and it is rewritten without abbreviations. For a condition-specific handout, the patient education handout template is the better starting point.
Sources
Built by
Chandler Supple
Co-founder & CEO, River
Chandler has spent the last six years working in AI, building tools for millions of users and Fortune 100 companies. In 2025, he co-founded River to build a new kind of operating system for AI agents.
Discharge Summary From Hospital Notes
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