Ward work & theatre careFree in the app
Discharge summary and referral letter
What the next doctor needs to know.
Source: Good practiceDischarge summary
- Diagnosis and procedures done, with dates.
- Mode of birth, baby outcome, blood loss, complications.
- Drugs on discharge, including LMWH duration and iron.
- Contraception advice; anti-D and rubella status.
- Follow-up: who, where, when; results to chase.
- Red flags to return for: heavy bleeding, fever, leg or chest pain, headache, low mood.
Referral letter
- Reason for referral and urgency.
- Summary of history, findings and results.
- What treatment has been given.
- What you want the receiving team to do.
- Your contact details.
A summary for trained clinicians. Always check the full guideline, the patient in front of you and your hospital's protocol. Spotted an error? Tell us.