Discharge summary format for normal delivery, LSCS and newborn: free Word & PDF templates.

One file, three templates on separate pages: normal (vaginal) delivery, LSCS / caesarean section, and newborn. Bracketed text shows what goes in each field; delete rows you do not use and put your own letterhead at the top.

Rather fill it in on screen? The free discharge summary generator has these templates plus general surgery, medical, LAMA and death summaries, it prints on your letterhead and writes medicines out in plain words, and patient details never leave your browser.

• Word template (.docx), editable; add your logo, remove rows, save as your hospital’s standard.
• PDF template, print-ready A4, for wards that still fill by hand.

Free to use and adapt for your own hospital or clinic. No email address, no registration. If you improve it, we would genuinely like to see the result.

The outline is not a matter of house style. Two documents set it out in practice. NABH’s entry-level standard (2nd Edition, AAC.7) lists what the summary contains: patient name and unique ID, treating doctor, dates of admission and discharge, reason for admission, significant findings, investigation results, diagnosis, procedures and other treatment, medication given, and condition at discharge. It adds that it is signed by the treating doctor, a copy stays in the record, advice is written so the patient understands it, the standard says medical terms such as BD, TDS and QID should not be used, and it tells the patient when and how to get urgent care. The National Standard for Patient Discharge Summary published by the TPA Medi Assist asks for the same core plus admission and discharge times, method of admission, the signing doctor’s designation and registration number and, for maternity, the obstetric score (GPLA).

The Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 add the record-keeping duties: keep indoor records for three years, and give a patient their records within 72 hours of a request. Everything else in the templates below is the obstetric detail that sits on that skeleton.

Three practical rules sit on top of that outline, and they are where hand-written summaries most often fail:

• Times, not just dates. Admission time, delivery time, discharge time. Insurers compute length of stay from them; the IPD register must agree with them.
• Names with registration numbers. The discharging doctor, the surgeon, the anaesthetist. A summary signed with an illegible initial is a summary an assessor cannot attribute.
• The patient’s acknowledgement. A line confirming the advice was explained in a language she understands, in Gujarat, that usually means the advice was given in Gujarati even if the summary is in English.

Beyond the standard skeleton, the obstetric record needs to reconstruct the delivery for someone who was not there, the doctor she sees at six weeks, or the one who manages her next pregnancy:

A caesarean is a surgery, so the summary is also an operative record. Everything above still applies, and the following are added, each one a field that an insurer, a future obstetrician or a medico-legal reviewer will ask for by name:

• Indication for LSCS, and whether elective or emergency.The most-queried field on maternity claims. “Foetal distress” without supporting notes in the file is a query waiting to happen.
• Incision type, skin and uterine. A lower-segment transverse incision is the basis for counselling on vaginal birth after caesarean; anything else changes the advice for every future pregnancy.
• Anaesthesia and anaesthetist; surgeon and assistant with registration numbers.
• Intra-operative findings and events, blood loss, units transfused.
• Tubal ligation, if performed, with consent on file, a sterilisation without a documented consent is a serious finding.
• Wound status at discharge and the suture-removal date; thromboprophylaxis given.
• Advice specific to surgery, wound care, lifting and activity limits, and the recommended interval before the next pregnancy.

The commonest structural error in maternity discharge paperwork is writing the baby into the mother’s summary as a line: “live male baby, 3.1 kg”. The baby is a separate patient with a separate future, a paediatrician, an immunisation schedule, a growth chart, and needs a document of their own:

• Identification, “baby of” with the mother’s name and UHID, sex, date and time of birth.
• Birth details, gestational age and term status, mode of delivery, birth weight, length, head circumference, APGAR at one and five minutes, any resuscitation.
• Course, feeding established, urine and stool passed, jaundice and any phototherapy, vitamin K given.
• Immunisations given at birth, BCG, OPV-0 and the hepatitis B birth dose, with dates, and the next dose due. This is the line the immunisation clinic will ask to see.
• Screening done, per your hospital’s protocol.
• Weight at discharge, feeding advice, danger signs a parent can recognise, follow-up.

Maternity claims are queried more for missing paperwork than for clinical reasons. From what hospitals report back, the fields that generate the query letter are consistently these, confirm the exact requirements with the insurer or TPA you work with most:

1. Admission and discharge dates with times, agreeing with the IPD register and the bill.
2. A final diagnosis that matches the procedure billed, with an ICD-10 code where the insurer asks for one.
3. For LSCS, the indication and whether it was elective or emergency.
4. Surgeon and anaesthetist names and registration numbers.
5. Investigations with results, not just a list of tests ordered.
6. Policy number, TPA and pre-authorisation number where a cashless approval exists.
7. Legible signature and hospital seal.

Every one of these is a reconciliation between the summary and something else, the register, the bill, the pre-authorisation. That is the argument for generating the summary from the same record as the admission rather than typing it fresh; the move from registers to software is largely the move from documents that can disagree to documents that cannot.

• No discharge time. Length of stay becomes an argument.
• Anti-D not recorded for an Rh-negative mother, even when it was given.
• Newborn on the mother’s summary, with no birth weight or immunisation record of its own.
• Advice without danger signs, “review SOS” is not an instruction a family can act on.
• Follow-up undated.“After 6 weeks” becomes never.
• Summary and register disagree, different dates, different spelling of the name, a procedure on one and not the other. This is the finding inspectors and TPAs both make.
• The only copy left with the patient. Retain yours, indoor records must be kept for at least three years under the 2002 Regulations, and the discharge summary is the record most often requested later.

A template makes every consultant’s summary look the same. It does not stop the nurse re-typing the admission date, the delivery time and the baby’s weight from three different registers on discharge morning, which is where the disagreements come from. The fix is structural: the summary should be assembled from fields that were captured during the stay, so the delivery time on the summary is the delivery time that was recorded in the labour room register, not a recollection.

That is how MedStream does it. A maternity admission carries the ANC episode, the labour-room and OT documentation and the newborn on one family record, and the discharge pack, summary, advice and the Gujarati feedback form, is assembled into one branded PDFfrom what is already there, in English or Gujarati. Whether you use our software or anyone else’s, ask to see a discharge summary generated live from a test admission in the demo; it is the fastest way to find out whether “discharge summary” on the feature list means a template or a record. Our printable buyer’s checklist has the question on it, and the clinical & maternity tour shows the pack in context.