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Dictate the stay once. Get the discharge summary in its sections.

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Verbato writes a discharge summary from your dictation.

For physicians who discharge patients from the hospital.

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What is a discharge summary?

A discharge summary is the physician's account of a hospital stay for the clinicians who follow: why the patient was admitted, what was found and done, the condition at discharge, the medications and the follow-up.

In practice

The primary care physician who sees the patient next depends on it, and it often arrives late or incomplete. A review in JAMA found a discharge summary available at the first post-discharge visit in only 12% to 34% of cases, which affected the quality of care in about a quarter of follow-up visits. Summaries often lacked diagnostic test results (33% to 63%), discharge medications (2% to 40%), follow-up plans (2% to 43%) and the tests still pending at discharge (65%). Standardized formats that highlight the most pertinent information improved the documents' perceived quality (Kripalani et al., 2007).

Further reading: The Royal College of Radiologists' standards for reporting imaging; Weed (1968), on the problem-oriented record the SOAP note comes from

What you say, and the discharge summary you get back

Illustrative example

The transcript excerpt and the document are written to show the format. Every name, figure and quote is invented.

What you say · transcript excerpt

discharge medications colon amoxicillin clavulanate eight seventy five milligrams by mouth twice daily for three more days period metformin five hundred milligrams scratch that metformin one thousand milligrams by mouth twice daily period new paragraph plan and follow up colon follow up with primary care in one week period repeat chest x ray in six weeks period return for fever or shortness of breath period

  • appears in this excerpt
  • no mark: from a part of the recording not shown here

What comes back · discharge summary

Admission and discharge dates

Admission: October 19. Discharge: October 24.

Reason for admission

Fever and productive cough with hypoxemia; community-acquired pneumonia of the right lower lobe.

Reason for discharge

Clinical improvement; discharged home.

Final diagnoses

Right lower lobe community-acquired pneumonia, resolving.

Type 2 diabetes mellitus.

Hospital course

Treated with intravenous ceftriaxone and azithromycin, changed to oral therapy on day 3. Oxygen weaned to room air by October 22. Glucose managed with basal insulin.

Condition at discharge

Stable, afebrile, oxygen saturation 95% on room air.

Relevant results

White count fell from 16.2 to 8.1. Blood cultures negative.

Allergies

Not dictated.

Discharge medications

Amoxicillin-clavulanate 875 mg by mouth twice daily for 3 more days. (appears in this excerpt)

Metformin 1000 mg by mouth twice daily. (appears in this excerpt)

Plan and follow-up

Follow up with primary care in 1 week. (appears in this excerpt)

Repeat chest X-ray in 6 weeks. (appears in this excerpt)

Return for fever or shortness of breath. (appears in this excerpt)

Prognosis

Good.

Procedures performed · Pending problems · Risk factors addressed — also part of a discharge summary; nothing in this example's recording calls for it, so it is left out.

Illustrative example

End of the illustrative example. Neither the excerpt nor the document was produced by Verbato.

What it looks like

Verbato's project screen: the discharge summary, in its sections, with the transcript folded beside it and a box to ask for a change.
  1. The transcript, folded beside the document: one press opens it, line by line with times.
  2. The document, in its sections.
  3. A change, asked for in your own words.

Verbato's app. The content was written to show it.

A blank discharge summary to copy

Admission and discharge dates

The dates of admission and discharge.

Reason for admission

Why the patient was admitted.

Reason for discharge

Improvement, transfer or another reason, and where the patient went.

Final diagnoses

The diagnoses at discharge, with their certainty.

Procedures performed

The procedures and operations of the stay.

Hospital course

How the stay went and how the patient was managed.

Condition at discharge

The clinical, functional and mental state at discharge.

Relevant results

The results that matter for what comes next, and any still pending.

Allergies

The allergies, or a statement that none are known.

Discharge medications

Each medication with its dose, route, frequency and duration.

Pending problems

The problems still open at discharge.

Plan and follow-up

Treatment at home, follow-up and warning signs.

Risk factors addressed

Tobacco, alcohol and other risk factors, and what was done.

Prognosis

The physician's prognosis.

Cause of death

Only when the patient died: the causes and any autopsy.

How your discharge summary is written

  • A section you did not dictate is left out, never filled in.

  • Allergies are always written, and the summary says so when you never mentioned them.

  • Medications keep the dose, route and frequency you dictated.

  • The word-for-word transcript sits beside the summary, so you check before you sign.

Your format, not ours

The sections of your discharge summary and the way it is written are yours to change. To fix a document, say what is wrong in your own words.

  1. 1You correct it

    “Call the ‘Hospital course’ section ‘Hospital stay’.”

    That discharge summary changes. Nothing else does.

  2. 2You say it again

    Make the same correction on a later discharge summary and Verbato asks: “You've changed this before. Always?”

  3. 3You decide

    Answer “Always” and it is kept as a rule, applied from your next discharge summary on. Answer “Just this once” and nothing is kept. Documents already written stay as they are, and nothing becomes a rule unless you confirm it.

  4. 4Your rules

    I call the “Hospital course” section “Hospital stay”.Undo

    Every rule you have kept is listed, and you can undo any of them. An undone rule stops applying from your next discharge summary.

How it works

Upload a file, paste a link, record in your browser, or send a voice note by Telegram or email. Verbato makes a word-for-word transcript, which you can edit and which stays beside the document. Your discharge summary is written from it, in minutes.

Recording limits

A recording made in your browser can run up to 30 min on every plan; a longer session goes in as a file you upload. A free account takes recordings of up to 40 min each; for longer ones, see pricing.

Your recording

Deleted after 7 days by default, together with its transcript and documents. You can keep a project longer, up to your plan's limit. Deleting a recording leaves a receipt you can download. Nothing you record is used to train or improve AI models. Recording patients or clients? Read what Verbato does with sensitive recordings.

Questions about the discharge summary

What is the difference between a discharge summary and discharge instructions?
The discharge summary is the physician's record of the stay for the next clinician: diagnoses, course, results, medications and follow-up. Discharge instructions are written for the patient, in plain words, and usually draw on the same plan.
Can I dictate the sections in a different order?
Yes. Say a section's name and carry on: what follows goes into that section, whatever order you dictate in. Within a section, the items keep the order you gave them.
What if I correct a dose in the middle of a sentence?
When you dictate to Verbato, say “scratch that” or “correction” and carry on. The summary takes the corrected dose and leaves out the slip. The transcript still shows everything you said.
What happens to the allergies if I don't mention them?
The Allergies section is always written. If you never mention allergies, it says “Not dictated.”, so the summary never suggests the patient has none.
How do I get the summary into the hospital's record?
Copy the discharge summary, or export it as a Word document, a PDF or plain text, and paste it where you sign. Verbato has no built-in connection to your hospital's record system.

The guide

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