Discharge Nursing Note Example
A discharge note documents the patient's condition at discharge, the instructions reviewed, how understanding was evaluated, and how the patient left.
Educational use & privacy
Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.
Nursing Notes Privacy & SafetyContent status: Draft — not yet professionally reviewed.
Why it is structured this way
The discharge note is the last nursing entry for the stay. It should show what was taught and how learning was checked, not just that papers were handed over.
When this may be used
- At discharge, per facility policy.
- Documentation requirements, frequency and screens vary by organization, setting and EHR. Follow your program's and facility's policy.
Components
Condition
Status at discharge.
What belongs here
- Findings actually obtained
What does not belong
- Copied admission findings
Instructions
Teaching.
What belongs here
- Topics reviewed and with whom
What does not belong
- "Instructions given" only
Evaluation
Understanding.
What belongs here
- Teach-back actually performed and result
What does not belong
- Automatic "verbalized understanding"
Devices
Lines, drains.
What belongs here
- Removed per order, site condition
What does not belong
- Unverified removal
Departure
How they left.
What belongs here
- Time, method, companion
What does not belong
- Guesses
Short fictional example
- Narrative
- 1430: Discharged home by wheelchair to car with spouse. Discharge instructions reviewed; patient explained when to call the clinic using the instruction sheet.
More detailed fictional example
- Condition
- Alert and oriented ×4. SpO2 96% on room air. Patient rates pain 0/10.
- Instructions
- Reviewed medication schedule, follow-up appointment date, and warning signs listed on the discharge sheet with patient and spouse.
- Evaluation
- Patient stated the antibiotic schedule as "one pill twice a day until they're gone" and named two warning signs from the sheet.
- Devices
- IV removed per order; catheter tip intact; site without bleeding.
- Departure
- 1430: Left unit by wheelchair with spouse.
Annotated example
Notes on the detailed example above:
named two warning signs from the sheet
— Specific teach-back instead of a canned phrase.catheter tip intact
— Device removal is documented specifically.
Common mistakes
- Only "discharge instructions given."
- No evaluation of learning.
- Charting departure before it happens.
Good vs poor documentation
Weaker (fictional)
D/C'd home, understands instructions.
Stronger (fictional)
Patient stated antibiotic schedule and named two warning signs from the discharge sheet.
Why: Evidence of learning.
Blank educational template
Discharge note: What was reviewed and how the patient left. Prompts only; nothing is prefilled.
- Condition at discharge
- [Findings actually obtained]
- Instructions reviewed
- [Topics reviewed and with whom]
- Evaluation of understanding
- [Teach-back actually performed and result]
- Lines / devices
- [Removed or in place, per order]
- Departure
- [Time, method, accompanied by]
Practice this format
- Practice Note Builder — write a practice note from a fictional scenario.
- Documentation practice questions
Related documentation guides
Sources
- ANA's Principles for Nursing Documentation (2010) — American Nurses Association.
- Nursing Fundamentals 2e — 2.5 Documentation — Open RN (Chippewa Valley Technical College).
- Fundamentals of Nursing — 14.5 Guidelines for Effective Documentation — OpenStax.
All examples on this page are original and fictional. Sources are used to check principles; they do not endorse Dosage Calcs. See Privacy & Safety.