Short answer
Under the NABH hospital standards (6th edition), every patient leaving the hospital, including one leaving against medical advice, must receive a discharge summary with standardised content. It must give follow-up advice, medication and other instructions in an understandable manner, and say when and how to obtain urgent care; after a death, it must include the cause of death. Most hospitals also record diagnosis, course in hospital, procedures, investigations, implants and the signing doctor.
What is a discharge summary?
A discharge summary is the document a hospital gives a patient when they leave after an inpatient stay. It tells the patient, their family and the next doctor what happened during the admission and what to do next: why the patient was admitted, what was found, what was done, which medicines to take and when to come back. A signed copy also stays in the hospital's medical record.
The same document is used well beyond the ward. Insurers and Third Party Administrators (TPAs) ask for it with every claim, government schemes need it for settlement, and under ABDM it is one of the record types a hospital can share with the patient's consent. A discharge summary that is complete, legible and consistent with the bill saves time for everyone. Terms used here, such as LAMA and UHID, are defined in our glossary.
What NABH requires in the 6th edition
The NABH Accreditation Standards for Hospitals, 6th edition, effective from 1 January 2025, deal with the discharge summary mainly in the Access, Assessment and Continuity of Care (AAC) chapter, with related requirements in the medication (MOM) and information management (IMS) chapters. NABH does not publish one mandatory form. Instead, each hospital defines the content of its own summary and keeps it standard.
| Standard | What it says, in short | What it means for your format |
|---|---|---|
| AAC.12 (discharge process) | Discharge is planned with the patient or family, coordinated across departments, and a discharge summary is given to every patient leaving, including those leaving against medical advice | One format for routine discharges, LAMA, transfers and deaths, never skipped |
| AAC.12 (discharge time) | The hospital monitors discharge time, sets benchmarks and improves | Record when discharge was approved and when the patient left |
| AAC.13 a and b | A summary is provided at discharge and has standardised content | A hospital-approved template used by every doctor |
| AAC.13 c | It contains follow-up advice, medication and other instructions in an understandable manner | Plain-language medicines, follow-up and care instructions |
| AAC.13 d | It includes when and how to obtain urgent care | Warning signs and an emergency contact number |
| AAC.13 e | After a death, the summary includes the cause of death | A death summary section |
| MOM.10 d | Batch and serial numbers of implants and medical devices are recorded in the medical record, the master logbook and the discharge summary | An implant section with batch and serial numbers |
| IMS.3 and IMS.4 | Entries are signed, dated and timed with an identifiable author, only authorised abbreviations are used, and the record holds a signed copy of the discharge summary | Signature block with name, date and time; approved abbreviations only |
Discharge summary fields: a field-by-field table
The table below combines the points NABH requires with fields most hospitals add as good practice. The last column also shows which sections line up with the Discharge Summary Record profile in the FHIR Implementation Guide for ABDM published by NRCeS, which matters when records are shared through ABDM.
| Field | What to record | Basis |
|---|---|---|
| Hospital details | Name, address, phone, registration or HFR ID if any | Good practice |
| Patient identity | Name, age, sex, hospital ID (UHID) and IPD number, ABHA if linked | Required: unique identifier (IMS) |
| Admission and discharge | Dates and times, ward, type of discharge (routine, LAMA, transfer, death) | Required: AAC.12 |
| Treating team | Consultant in charge, department, other consultants | Good practice |
| Reason for admission | Presenting complaints and their duration | Required: IMS.4; FHIR section ChiefComplaints |
| History and allergies | Relevant past and family history, known allergies | Good practice; FHIR MedicalHistory, Allergies |
| Findings on admission | Key examination findings and vital signs | Good practice; FHIR PhysicalExamination |
| Diagnosis | Final diagnosis and other conditions; codes if your hospital uses them | Required: IMS.4 |
| Investigations | Significant results with dates | Required: IMS.4; FHIR Investigations |
| Procedures | Operations and procedures with dates and the operating doctor | Required: IMS.4; FHIR Procedures |
| Implants and devices | Name, batch number and serial number | Required: MOM.10 |
| Course in hospital | Short account of treatment and progress | Required: IMS.4 (care provided) |
| Condition at discharge | General condition and vital signs at discharge | Good practice |
| Medicines at discharge | Name, dose, route, timing, duration; changes from earlier medicines | Required: AAC.13 c; FHIR Medications |
| Follow-up | Date, doctor or department, tests to bring | Required: AAC.13 c; FHIR CarePlan |
| Other instructions | Diet, activity, wound or device care, in plain language | Required: AAC.13 c |
| Urgent care | Warning signs and whom to call, with a number | Required: AAC.13 d |
| Cause of death | Only when the patient has died | Required: AAC.13 e |
| Sign-off | Doctor's name, registration number, signature, date and time | Required: IMS.3 |
| Acknowledgement | Patient or attendant's name and signature on receipt | Good practice |
A plain-text discharge summary template
You can copy the outline below into your word processor or hospital software and adapt it. Keep the order fixed and replace each bracket with the actual content.
- Header: [Hospital name, address, phone] [Registration or HFR ID] Title: DISCHARGE SUMMARY [or: DISCHARGE SUMMARY (LAMA) / TRANSFER SUMMARY / DEATH SUMMARY]
- Patient details: Name [ ] Age/Sex [ ] UHID [ ] IPD No. [ ] ABHA (if linked) [ ] Address and phone [ ]
- Admission details: Date and time of admission [ ] Date and time of discharge [ ] Ward/Bed [ ] Consultant in charge [ ] Department [ ] Payer: self / insurer or TPA / scheme [ ]
- Reason for admission: [Presenting complaints with duration]
- Relevant history and allergies: [Past illnesses, surgeries, family history] Allergies: [None known / details]
- Findings on admission: [Key examination findings and vital signs]
- Diagnosis: Final diagnosis [ ] Other conditions [ ]
- Investigations: [Significant results with dates; attach reports]
- Procedures: [Name of procedure, date, operating doctor, anaesthesia type]
- Implants and devices: [Name, batch number, serial number] or "None"
- Course in hospital: [Short account of treatment given and progress]
- Condition at discharge: [General condition, vital signs]
- Medicines at discharge: [Table: medicine, dose, route, timing, duration, note of any change from earlier medicines]
- Follow-up: Visit on [date] with [doctor/department]. Bring [reports/tests].
- Instructions: Diet [ ] Activity [ ] Wound or device care [ ] Other [ ]
- When to seek urgent care: Return or call [phone number] immediately if [warning signs listed by the treating doctor].
- Death summary (only if applicable): Date and time of death [ ] Cause of death [ ]
- Sign-off: Prepared by [name] Approved and signed by [doctor's name, registration number, signature] Date and time [ ]
- Acknowledgement: Received by [patient or attendant's name, relationship, signature, date]
Special cases: LAMA, transfers and deaths
- Leaving against medical advice (LAMA): NABH requires a summary here too. Record the advice and risks explained, and the acknowledgement.
- Transfer to another hospital: add the reason for transfer, the receiving hospital and doctor, the condition at transfer and what was handed over.
- Death: use the death summary section with the cause of death, and keep a copy of the medical certificate of cause of death in the record.
How do you write a discharge summary patients understand?
NABH asks for instructions in an understandable manner, so write the patient-facing sections for the patient, not for another doctor.
- Write medicines as a table with clear timings (morning, afternoon, night, before or after food) and the number of days.
- Use only the abbreviations on your hospital's approved list, and avoid them in the patient sections.
- Give a copy in the patient's language where you can, or explain the instructions to the attendant at discharge.
- List warning signs in simple words and print a phone number that is answered day and night.
How software fills the discharge summary from the IPD record
When the hospital runs IPD management in software, most sections can be drawn from records already made during the stay, and the doctor reviews, edits and signs instead of writing from scratch.
| Summary section | Source in the IPD record |
|---|---|
| Reason for admission, history, findings | Initial assessment by the admitting doctor |
| Investigations | Lab and imaging reports linked to the admission |
| Procedures and implants | OT notes and the implant entry with batch and serial numbers |
| Course in hospital | Progress notes and doctor rounds |
| Medicines at discharge | Medication chart, edited by the doctor for home use |
| Sign-off and times | The user's login, with date and time recorded automatically |
Two other benefits follow. The final bill, reports and summary carry the same names and dates, which reduces insurer queries; our guide to PM-JAY, TPA and insurance claims explains why that matters. And where the software supports ABDM, the signed summary can be linked to the patient's ABHA and shared with consent; see ABDM and ABHA.
Discharge time and the NABH indicator
The 6th edition asks hospitals to monitor discharge time and lists "time taken for discharge" among its key performance indicators, measured from the consultant formally approving discharge until the patient leaves the clinical unit. A summary ready at the moment of approval shortens it. Our guide to NABH documentation covers the other indicators software can calculate.
Common mistakes
- Each doctor using their own format, so content varies from patient to patient.
- Leaving out urgent care instructions or implant batch and serial numbers.
- Unsigned summaries, or summaries without the date and time of signing.
- A summary with dates or names that differ from the final bill.
How Sehat Nxt helps
In Sehat Nxt IPD management, each admission has a patient file with signed records, and the discharge summary, reports and documents are attached to the same admission. Doctors and nurses can fill IPD forms by voice, and the case file prints on your letterhead in date order. Charges reach the final bill through hospital billing, so the bill and the summary come from one record. Sehat Nxt is ABDM M1, M2 & M3 Ready.
Plans start from ₹999 per month. Book a free demo and bring your current discharge summary format to compare.
Frequently asked questions
Is there an official NABH discharge summary format?
No single form is prescribed. The NABH 6th edition asks each hospital to define standardised content that includes follow-up advice, medication, other instructions, when and how to obtain urgent care and, after a death, the cause of death, and to give a summary to every patient leaving.
Do LAMA patients need a discharge summary under NABH?
Yes. The 6th edition requires a discharge summary for all patients leaving the hospital, including those leaving against medical advice, and written guidance for the LAMA process.
Should implant details be in the discharge summary?
Yes. NABH's medication management chapter expects the batch and serial numbers of implantable prostheses and medical devices to be recorded in the medical record, the master logbook and the discharge summary.
Who should sign the discharge summary?
The treating doctor or another authorised doctor, with name, registration number, signature, date and time. NABH expects each entry to be signed, dated and timed with an identifiable author, and a signed copy kept in the medical record.
Can the discharge summary be shared through ABDM?
Yes, when the hospital's software supports ABDM record sharing (milestone M2) and the patient consents. NRCeS publishes a Discharge Summary Record profile in the FHIR Implementation Guide for ABDM for this purpose.
Related guides
Sources
Related Sehat Nxt features
- IPD ManagementAdmissions, beds, OT stages, signed patient files and discharge, with voice dictation on IPD forms.
- Hospital BillingOPD and IPD bills, deposits, payment modes, payer and TPA claims, with day book and GST reports.
- ABDM & ABHAABHA creation and verification, Scan & Share at the desk, and linking records to ABHA. ABDM M1, M2 & M3 Ready.