Discharge Summary

A discharge summary is the hospital's narrative medical document, prepared by the treating doctor at the time the patient is released from hospital, that records the entire course of the hospitalisation in clinical terms. It is the single most important document in any health insurance claim — every other document either supports it or follows from it. The discharge summary typically captures the date of admission and discharge, the chief complaint at admission, the relevant past medical history, the on-admission examination findings, the diagnosis (with ICD codes on most modern hospitals' templates), the line of treatment (medical management, surgical intervention, intensive care, blood transfusions), the procedures performed (with CPT or local procedure codes), the medications administered, the patient's progress through the stay, the condition at discharge, and the follow-up advice for medications, diet, activity, and review consultations.

The treating doctor's signature, registration number, and the hospital's stamp authenticate the document. Worked example: Sundar is admitted for three days for a recurring kidney-stone obstruction. The discharge summary the urologist prepares captures the chief complaint (right-sided flank pain with vomiting), the past history (a previous similar episode in 2022 treated conservatively), the on-admission ultrasound finding (an 8mm calculus at the right vesico-ureteric junction with mild hydronephrosis), the procedure (ureteroscopic stone removal with stent placement), the post-op course, and the follow-up plan (stent removal in three weeks, increased fluid intake, follow-up CT-KUB in three months).

This discharge summary, attached to the claim form, is what the TPA's medical reviewer reads to confirm that the hospitalisation was medically necessary, the procedure was appropriate, and the diagnosis is consistent with the bill. A common misconception is that 'the bill alone is enough for a claim'. It is not.

The bill is a financial document; the discharge summary is the medical document that explains why the bill was incurred. Without the discharge summary, the claim cannot be evaluated, and the TPA will mark the file 'pending documentation' until it arrives. Another common misconception is that 'a hand-written discharge sheet from the duty doctor is the same as a discharge summary'.

It is not — the formal discharge summary is a typed document on hospital letterhead, signed and stamped, and it is the document insurers expect. Always collect the discharge summary at the time of discharge and verify that the diagnosis, procedures, and medications match what was actually done; corrections after discharge are administratively painful. Related: claim-form, reimbursement-claim, cashless-claim.