The Discharge Summary Is Missing: Who Should Follow Up?
A missing discharge summary can mean several different things.
The family may not have a copy. The receiving facility may be waiting for a transition record. The hospital’s complete narrative summary may still be awaiting authentication. Or the receiving clinician may have enough immediate information to begin care but still need additional records.
First identify what is missing, who needs it, and whether the missing information affects care right now.
CMS hospital guidance requires hospitals to transmit necessary medical information to appropriate post-acute providers at discharge. CMS also expects discharged-patient records to contain a discharge summary addressing the hospitalization outcome, disposition, and follow-up care. The patient-facing packet and the provider-to-provider discharge summary are related but not necessarily identical documents.
Ask what document is actually missing
Use precise language.
Patient discharge instructions
These are the instructions the patient and family use: medications, follow-up appointments, warning signs, activity limits, equipment, and contact information.
Transition or referral information
This is clinical information sent to the next provider so it can continue care.
Formal discharge summary
This is the hospital’s summary of the hospitalization and follow-up plan in the medical record.
Full medical record
This is broader than the discharge summary and may include many notes, test results, imaging, procedure reports, and other records.
If the receiving nurse says, “We don’t have the discharge summary,” ask:
“Which information do you need now to safely continue care, and which document can follow through medical records?”
That question is more useful than assuming the entire chart must be reproduced before anyone can act.
Start with the hospital discharge team
If the patient has not left yet, tell the discharge planner, nurse, or case manager that the receiving provider reports missing information.
Ask the hospital to confirm:
- what information was sent;
- when it was sent;
- where it was sent;
- whether there was a transmission confirmation;
- who at the receiving facility should receive it; and
- what remains outstanding.
If the patient already left, the same hospital contacts may still help, but the medical-records department or responsible clinician’s office may become part of the process.
Let the receiving team identify what is urgent
A delayed narrative summary does not make it safe for a family to guess at medications, orders, or follow-up instructions.
Ask the receiving clinician or nurse whether they have the current information needed for:
- medications and next doses;
- allergies;
- diagnoses and current problems;
- treatments or procedures;
- wound or device care;
- diet or swallowing instructions;
- activity or mobility restrictions;
- pending tests;
- follow-up appointments; and
- who is responsible for unresolved clinical questions.
If any immediate order is unclear, ask the responsible clinicians to resolve it directly.
Do not use an ordinary directory contact form to move medical records
Medical records should travel through the providers’ approved secure processes.
A family may have legitimate access to copies of records, but that does not make ordinary email, a facility marketing form, or a directory inquiry box the right transfer method.
If you are asked to upload or email records, verify that the destination actually belongs to the receiving provider and that it is the method the provider instructs you to use.
Escalate in a simple order
Use this sequence when a needed summary cannot be located:
- Receiving nurse or admissions contact: identify the exact missing document or information.
- Hospital discharge planner/case manager: verify what was sent and correct the destination if needed.
- Hospital unit or responsible clinician: resolve urgent clinical questions.
- Hospital medical records/health information management: request or route the finalized record when appropriate.
- Patient relations or supervisor: use when communication is stalled and the missing information is affecting the transition.
Do not call every department simultaneously unless there is an urgent safety problem. One owner and one timestamped log are easier to manage.
Missing-summary follow-up tracker
| Item | Status |
|---|---|
| Receiving facility/contact | |
| Document or information missing | |
| Immediate-care impact | None / Possible / Urgent |
| Hospital contact notified | |
| Date/time notified | |
| Transmission destination verified | |
| Resent/released by | |
| Receiving team confirmed receipt | |
| Unresolved clinical question | |
| Responsible clinician | |
| Next follow-up time |
What if the summary contains an error?
Do not edit the medical document yourself.
Mark the disputed item and contact the hospital or clinician that created the information. If the error involves the medication plan, diagnosis, allergies, or follow-up care, ask for clinical clarification promptly.
A receiving facility may need a corrected order or documented clarification rather than a family annotation.
Frequently asked questions
Should the patient receive the full discharge summary before leaving?
Medicare’s discharge-planning checklist advises patients to ask for written discharge instructions and a summary of current health status. The formal provider discharge summary and the patient-facing packet may not be the same document. Ask the hospital what it provides directly to patients and what it transmits to the next provider.
Can the nursing home admit someone if the final narrative summary is not in hand?
Admission and information requirements depend on the setting, state rules, the patient’s needs, and the facility. The better question is whether the receiving clinical team has the information and orders it needs to safely begin care.
What if the missing record contains pending test results?
Ask who is responsible for reviewing each pending result and how the result will reach the clinician caring for the patient after discharge. Do not assume that “pending” means no follow-up is needed.
Related NHP guides
- https://nursinghomeplacement.com/nursing-home-admission-documents-checklist/
- https://nursinghomeplacement.com/hospital-discharge-planner-questions/
- https://nursinghomeplacement.com/how-to-organize-an-older-parent-s-medication-list-before-a-move/
Primary sources checked
- CMS — Hospital Discharge Planning and transfer of necessary medical information: https://www.cms.gov/files/document/r238soma.pdf
- CMS — State Operations Manual hospital discharge-summary guidance: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/r238soma.pdf
- HealthIT.gov — Discharge Summary Note: https://isp.healthit.gov/uscdi-data/discharge-summary-note
- Medicare — Your Discharge Planning Checklist: https://www.medicare.gov/publications/11376-your-discharge-planning-checklist.pdf
*Editorial/source review: October 15, 2026. General information, not medical, legal, or privacy advice.*
