What a hospital discharge summary contains

When someone leaves the hospital, the treating team prepares a discharge summary. This document typically includes:

• The reason for admission
• The main diagnosis or diagnoses
• Procedures performed
• Medications prescribed (including any changes)
• The person's condition at the time of discharge
• Follow-up instructions and appointments
• Notes on any ongoing limitations or care requirements

This document is one of the most credible pieces of evidence available for a CLSC assessment. It is written by physicians, dated, and specific.

Why it matters for CLSC assessments

Hospitalization is a common turning point in a person's functional capacity. After a hospitalization for a fracture, stroke, heart procedure, or serious infection, the person's needs at home may be significantly greater than before admission.

A discharge summary provides:

• Objective confirmation of a health event — it removes any question of whether the event occurred
• Clinical context — the assessor can see what the person has been through medically
• Follow-up requirements — if the discharge summary recommends physiotherapy or wound care, this directly informs the care plan
• A clear before/after marker — helpful when arguing that needs have changed since the last assessment

How to obtain a hospital discharge summary

Immediately after discharge: The hospital typically provides a copy to the patient or to the family caregiver present at discharge. Ask for it at the time of discharge if you do not receive one automatically.

After the fact: Contact the medical records department of the hospital where the person was admitted. In Quebec, patients (and their authorized representatives) have the right to request copies of their medical records. There may be a small fee and a processing time of several days to a few weeks.

Through your family doctor: The discharge summary is typically sent to the family physician. Your doctor's office may have a copy that can be shared with you.

If there was no hospitalization

If a significant health change occurred outside a hospital (a new diagnosis from an outpatient clinic, for example), a letter from the physician or specialist is the equivalent document. See the Physician Letters article.

What should I gather next?

Return to the Medical Documentation Checklist to see what other records are useful to collect before your CLSC assessment.