A discharge summary is the document a hospital gives every inpatient when they leave — including patients who leave against medical advice — that records why they were admitted, what was found, what was done, their condition at discharge, and the medicines, advice and follow-up they need next. In India the same document is read by four audiences: NABH requires one for every patient with standardised content, insurers and TPAs require IRDAI's standard format with ICD-10 codes before they pay a claim, PM-JAY rejects claims without a complete one, and ABDM carries it to the patient's ABHA as a "Discharge Summary" health record. One well-designed template can satisfy all four.
This guide gives the complete section order, the fields each audience insists on, the rules for death, LAMA and DAMA cases, the legal timelines, and the habits that get the summary finished before the patient's family starts asking. It is written for medical superintendents, consultants, residents, nursing heads and TPA desks, and was reviewed on 5 November 2026.
Key takeaways
- Every patient gets one. NABH's 6th edition requires a discharge summary for all patients leaving the hospital, including those leaving against medical advice, given at the time of discharge.
- Insurers have a fixed format. IRDAI's 2016 standardisation guidelines tell hospitals to use the standard discharge summary format, which marks ICD-10 codes, past medical history, key investigations, course in hospital, advice and signatures as mandatory.
- Three hours, not a day. Under IRDAI's 29 May 2024 master circular, insurers must give final authorisation within three hours of the hospital's discharge request — which only works if the summary is ready.
- Death needs the cause. In case of death, the summary must include the cause of death.
- Records within 72 hours, kept at least three years. The Indian Medical Council (Professional Conduct) Regulations, 2002 — still in force — require indoor records to be kept for three years and supplied within 72 hours of a request.
The complete discharge summary format, section by section
This order combines the IRDAI standard format, NABH's content requirements and the practice of TPAs. Fields marked * are mandatory in the IRDAI standard discharge summary.
| # | Section | What to write |
|---|---|---|
| 1 | Hospital header | Hospital name, address, registration, contact and emergency number |
| 2 | Patient details | Name*, age, sex, contact number*, address |
| 3 | Identifiers | UHID, IP or admission number, ward and bed, ABHA number if linked |
| 4 | Dates | Date and time of admission and of discharge (dd/mm/yyyy) |
| 5 | Treating consultant | Name, specialty, contact and registration number; other doctors in the team |
| 6 | Medico-legal | MLC number and FIR number where applicable* |
| 7 | Diagnosis | Provisional diagnosis at admission; final diagnosis with ICD-10 code(s)* |
| 8 | Presenting complaints | Each complaint with its duration, and the reason for admission |
| 9 | History | Summary of present illness; significant past medical and surgical history* (for example, diabetes or hypertension with duration); family history; alcohol, tobacco and substance use |
| 10 | Examination | Key findings on admission, including vitals |
| 11 | Investigations | Key results with dates*, including imaging and pathology |
| 12 | Course in hospital | Treatment given and response, including complications* |
| 13 | Procedures | Surgery or procedure with date, surgeon, anaesthesia and key operative findings |
| 14 | Condition at discharge | Clinical status, vitals, mobility |
| 15 | Discharge medications | Generic name (in capitals), dose, route, frequency and duration |
| 16 | Advice* | Diet, activity, wound care, warning signs, in plain language the patient understands |
| 17 | Follow-up | Date, doctor and department; tests to bring |
| 18 | Urgent care | When and how to obtain urgent care, with a number that is answered |
| 19 | Signatures | Consultant or authorised doctor's signature* with name and registration number; patient or attendant signature* |
Discharge summaries for childbirth usually add gravida, parity, live and abortion details (GPLA) and the baby's details; trauma cases add the MLC and FIR numbers and the mechanism of injury.
What NABH requires
The NABH 6th edition hospital standards, in force since 1 January 2025, cover discharge in two standards of the Access, Assessment and Continuity of Care chapter. AAC.12 requires an established discharge process: coordinated discharge, including medico-legal and absconded cases; written guidance for patients leaving against medical advice; a discharge summary given to all patients, including those leaving against advice; and monitoring of discharge time against benchmarks the hospital sets. AAC.13 requires the hospital to define the summary's content: it is given at the time of discharge, has standardised content, explains follow-up, medication and other instructions in an understandable manner, says when and how to obtain urgent care, and, in case of death, includes the cause of death.
The 5th edition (2020) listed the content explicitly — patient name, UHID, treating doctor, dates of admission and discharge, reasons for admission, significant findings, diagnosis, investigation results, procedures, medication and other treatment, and condition at discharge. Assessors still expect those items. See NABH accreditation and hospital software.
What insurers and TPAs require
IRDAI's Guidelines on Standardization in Health Insurance (29 July 2016) tell network providers to follow the standard discharge summary format prescribed in Schedule C of IRDAI's TPA circular of 28 March 2016. The format lists name, contact, IPD number, consultant, dates and times, MLC/FIR, provisional and final diagnosis, ICD-10 codes, presenting complaints with duration, summary of illness, examination findings, alcohol, tobacco and substance history, past history, family history, key investigations, course and complications, advice, and the signatures of the doctor and the patient or attendant.
IRDAI's master circular on health insurance of 29 May 2024 then set the clock: cashless authorisation within one hour, and final authorisation within three hours of the hospital's discharge authorisation request, with any extra hospital charges caused by the insurer's delay borne by the insurer. It also says insurers and TPAs should collect documents from the hospital rather than the policyholder. In practice the three hours start only when the hospital sends a complete file — and the discharge summary is usually the last document ready.
Discharge summary problems that delay or reduce claims
- No ICD-10 code, or a diagnosis that does not match the pre-authorisation.
- Complaints without duration, which insurers need to judge pre-existing conditions and waiting periods.
- Past history left blank or written as "nil" when the investigations show long-standing diabetes or hypertension.
- Alcohol or substance history missing in cases where it is relevant to the diagnosis.
- Dates that differ between the summary, the bill and the case sheet, or dates overwritten by hand.
- No doctor's signature, name or registration number.
- Handwriting the reviewer cannot read.
Our guide to the IRDAI one-hour and three-hour rule covers the TPA desk workflow, and TPA claims management the rest of the file.
PM-JAY and Ayushman Bharat claims
State health agencies treat the discharge summary as compulsory for PM-JAY claims. Haryana's advisory to empanelled hospitals is typical: a discharge summary is a must and the claim is liable to be rejected if it is incomplete; every document must be signed and stamped by the treating doctor even when computer-generated; there must be no cutting or overwriting of dates; operation notes must be typed or clearly readable; and death cases need a death summary, clinical notes, investigation reports, CPR notes and the death certificate. See PM-JAY for patients aged 70 and above and claims through NHCX.
Death, LAMA and DAMA summaries
- Death summary: the course in hospital, the resuscitation attempted, the time of death and the cause of death (immediate, antecedent and underlying), signed by the doctor who certified it. NABH requires the cause of death to be part of the summary.
- LAMA (left against medical advice): NABH requires written guidance for these cases and a discharge summary for the patient. Record the advice given, the risks explained, who took the decision, and the signed refusal form.
- DAMA (discharge against medical advice), referral, transfer, absconded: state the type of discharge clearly at the top of the summary. A referral summary names the receiving hospital and the reason for referral.
Recording the discharge type as data, rather than in the text, also gives the hospital its LAMA and mortality rates without a manual count — see hospital KPIs.
The discharge summary as an ABDM health record
Under ABDM, the discharge summary is one of the health-information types a hospital shares to the patient's ABHA. The national FHIR implementation guide defines a DischargeSummaryRecord with sections for chief complaints, physical examination, allergies, medical history, family history, investigations, medications, procedures and care plan, plus any attached document. A hospital using ABDM-integrated software links the summary at discharge, and the patient can then share it with any other provider.
Discharge summaries also count as the highest-value record type under the Digital Health Incentive Scheme. Corrigendum 7, valid from April to September 2026, paid a hospital ₹10 for each KYC-verified discharge summary linked above the first 100 records a month. As of 5 November 2026 the ABDM website had not announced an extension beyond September; see DHIS for hospitals.
Legal timelines and record retention
- Supply within 72 hours. Regulation 1.3.2 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 requires a patient's medical records to be issued within 72 hours of a request. NMC's 2023 conduct regulations were held in abeyance in August 2023, so the 2002 regulations still apply.
- Keep indoor records at least three years. Regulation 1.3.1 requires indoor patient records to be maintained for three years from the start of treatment. Many hospitals keep them much longer: AIIMS keeps indoor and medico-legal records for ten years, and medico-legal records are usually kept until the case is closed.
- Legible, generic, preferably in capitals. Regulation 1.5, amended in 2016, requires generic drug names written legibly and preferably in capitals. In August 2025 the Punjab and Haryana High Court held that a legible prescription is part of the right to health.
- Electronic records. Where the Clinical Establishments Act applies, Rule 9(iv) of the 2012 central rules requires hospitals to maintain and provide electronic medical records in the form the government specifies.
- Data protection. Under the DPDP Act, a patient can ask for erasure of personal data, but retention required by law continues. See the DPDP timeline for hospitals.
How to cut discharge time
An audit of 100 surgical discharges at an Indian tertiary hospital, published in 2023, found 40% delayed, more often for insured patients, with the biggest causes being medicine indenting, late discharge intimation in the system and the summary itself. NABH does not fix a number of hours; it asks each hospital to set a benchmark and improve on it. What works:
- Start the summary on the day of admission. Fill demographics, complaints, history and examination from the case sheet, and add investigations and the course of treatment daily.
- Plan discharges the evening before and tell the pharmacy, billing and TPA desk at the morning round.
- Use templates by condition and procedure so residents edit rather than type from scratch.
- Let the consultant dictate. A voice note turned into a draft is faster than a typed summary, as long as a doctor checks and signs it.
- Send the TPA file the moment the summary is signed to start the three-hour clock.
- Measure it. Record the time of the discharge order, summary sign-off, bill settlement and the patient leaving, and review the gaps weekly.
Writing discharge summaries in Healthixio
Healthixio's IPD discharge screen holds every section above as a field: type of discharge, MLC and FIR numbers, surgery and its date, provisional and final diagnosis, chief complaints, clinical history, past, personal, family and other histories, allergies, examination, key investigations, course in hospital, treatment, doctors' team, condition at discharge, advice, post-discharge prescription, referral, follow-up date, and the cause of death and death summary when needed.
- Discharge types include Routine, LAMA, DAMA, Daycare, Refer to Higher Centre, On Request, Transfer, Absconded and Death, recorded as data.
- Your own layout: the hospital can reorder, rename or hide sections and add its own boxes — for example an ICD-10 code box for insurance cases — and the print follows that layout.
- Nothing lost: drafts save automatically on the screen every half-second and to the server every minute, and can be saved at any time before the bill is settled.
- Four print templates with the hospital's letterhead.
- Dictate it on WhatsApp: a consultant can send a voice note and the AI fills the summary's 17 fields as a draft for a doctor to check and sign — see discharge summary by voice note.
- Linked to ABHA at discharge as a Discharge Summary record for ABDM.
See the IPD module and the IPD workflow guide.
Frequently Asked Questions
What is a discharge summary?
A discharge summary is the document given to a patient on leaving hospital. It records the reason for admission, diagnosis, investigations, treatment and procedures, condition at discharge, medicines, advice and follow-up. It is needed for insurance and scheme claims and for the next doctor who treats the patient.
What is the NABH discharge summary format?
NABH's 6th edition requires standardised content defined by the hospital, given at discharge to every patient, including follow-up advice, medication and instructions in plain language, how to obtain urgent care, and the cause of death where applicable. The 5th edition's list — name, UHID, treating doctor, dates, reason for admission, findings, diagnosis, investigations, procedures, treatment and condition at discharge — remains the practical minimum.
Is a discharge summary mandatory for an insurance claim?
Yes. It is a core claim document, and IRDAI's guidelines tell hospitals to use the standard format. A missing ICD-10 code, an unexplained diagnosis or missing past history are common reasons for queries and delays.
Does a discharge summary need an ICD-10 code?
For insurance claims, yes: the IRDAI standard format marks ICD-10 code(s) as mandatory. Many hospitals add ICD-10 to every summary so the same document works for all payers.
How soon must a hospital give the discharge summary?
NABH requires it to be given at the time of discharge. Separately, the 2002 Professional Conduct Regulations require medical records to be supplied within 72 hours of a patient's request.
Can a hospital refuse the discharge summary until the bill is paid?
NABH requires a summary for every patient leaving the hospital, including those leaving against medical advice, and the 2002 regulations require records within 72 hours of a request. Withholding the summary as leverage for payment is not supported by these rules; billing disputes should be handled separately.
How long must hospitals keep discharge summaries and IPD records?
At least three years from the start of treatment under the 2002 regulations. Many hospitals keep them for ten years or permanently, and medico-legal records until the case is closed. Keeping them digitally makes retrieval within 72 hours practical.
What is the difference between a discharge summary and a death summary?
A death summary is the discharge summary for a patient who died in hospital. It records the course, resuscitation, time of death and cause of death, and is needed for claims along with the death certificate.
Make the discharge summary the fastest part of discharge
Start it at admission, dictate it if you like, and send it to the TPA and ABHA the moment it is signed. Book a demo of Healthixio's IPD and discharge workflow or see the screens on the product tour.
Sources
- IRDAI Master Circular on Health Insurance Business, 29 May 2024: copy of the circular
- IRDAI Guidelines on Standardization in Health Insurance, 29 July 2016: ibai.org
- IRDAI standard discharge summary format (TPA copy): Health India TPA
- ABDM FHIR implementation guide, DischargeSummaryRecord: nrces.in
- Haryana State Health Agency advisory on PM-JAY claim documents: s3waas.gov.in
- DHIS Corrigendum 7 and scheme page: abdm.gov.in
Last reviewed 5 November 2026. This guide is general information, not legal advice.