Chart summary formats, field by field
Short version: the 5 clinical chart summary formats share 8 core fields, but each puts a different field first. Pre-visit leads with what changed. Consult leads with the answer. Transfer leads with current status and pending work. Discharge leads with what the next clinician must do. Problem-list leads with what is active. Every field below cites the rule or standard that asks for it, where 1 exists.
Limits: Vendor facts come from each vendor's own website on 2026-11-12 and were not tested by us. Rules are summarized from the cited text; your hospital's bylaws, payer contracts and state law can ask for more.
2 kinds of source shape these formats. The first is regulation: the CMS Conditions of Participation for hospitals (42 CFR 482) and EMTALA (42 CFR 489.24) say what must travel with a patient. The second is the HL7 Consolidated CDA (C-CDA), the standard EHRs use to send these documents to each other. C-CDA version 5.0.0 marks some sections as required (cardinality 1..1) and others as "should" or optional. Where the 2 agree, the field is not optional in practice. We read both on 2026-11-12.
Pre-visit summary
Reader: the clinician about to see the patient, often the same person who writes it, or a nurse or medical assistant preparing it for them. When: 2 to 3 days before the visit, per the AMA's team-based care guidance, which lists reviewing the last visit's notes, checking a registry or visit-prep list for care gaps, and finding outside information such as hospital discharge notes, ED notes or operative notes. Rule: none at the federal level. It is a workflow tool, so the format is yours to set.
| Field | What to write | Why it is there |
|---|---|---|
| Visit reason and date | Scheduled reason in the patient's words, plus the date of the last visit | Frames everything below |
| What changed since last visit | ED visits, admissions, new diagnoses, outside results, each dated | The main job of the summary; AMA guidance names discharge, ED and operative notes |
| Active problems | 3 to 6 problems that matter today, each with status | Keeps the visit on the problems, not the history |
| Medication changes | Started, stopped, held, dose changed, by whom | Changes made by other clinicians don't show up in your last note |
| Results to review | New results since last visit, with dates; overdue tests | Lets you act on them in the room |
| Care gaps due | Screenings, vaccines, monitoring labs that are due | The registry check in the AMA list |
| Open loops | Referrals sent but not seen, results pending, prior authorizations | Things that close only if someone looks |
Common failure: it repeats the problem list instead of the changes. If nothing changed, say so in 1 line. That is useful information.
Consult summary
Reader: the physician who asked. When: after you see the patient, within the time your bylaws set for the urgency of the request. Standard: the C-CDA Consultation Note (LOINC 11488-4) requires allergies, history of present illness and a problem section, and says it should contain medications, physical exam and results.
| Field | What to write | Why it is there |
|---|---|---|
| The question | The consult question as asked, and as you understood it if different | First of Goldman, Lee and Rudd's 1983 consultation rules: determine the question |
| The answer | 1 to 2 sentences, at the top | The reader may stop here |
| Recommendations | Numbered, specific: drug, dose, route, duration, test, timing | "Consider" is not a recommendation |
| Contingency plan | "If X, then Y; call us if Z" | Also in the 1983 rules; covers the night after you leave |
| History of present illness | The part relevant to the question | Required in C-CDA (1..1) |
| Pertinent findings | Exam, results and pertinent negatives that support the answer | Shows your reasoning; C-CDA says should contain exam and results |
| Problems, medications, allergies | As they bear on the answer | Problems and allergies are 1..1 in C-CDA |
| Follow-up | Will you see the patient again, and when | Tells the team whether to call back or expect you |
Common failure: the answer sits on page 2 under a full review of systems. Put it first.
Transfer summary
Reader: the receiving team, at another unit or another hospital. When: before the patient leaves. Rules: under 42 CFR 482.43(b), a hospital must transfer or refer the patient along with all necessary medical information about the current course of illness and treatment, post-discharge goals of care and treatment preferences. Since July 1, 2025, 482.43(c) also requires written transfer policies and annual staff training. For a patient transferred from the emergency department under EMTALA, 42 CFR 489.24(e)(2)(iii) lists what must go: available history, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of them, treatment provided, test results, the transfer consent or certification, and the name and address of any on-call physician who refused or failed to appear. Records not yet available go as soon as practicable. Standard: the C-CDA Transfer Summary (LOINC 18761-7) requires allergies, medications, problems, reason for referral, results and vital signs.
| Field | What to write | Source that asks for it |
|---|---|---|
| Reason for transfer | What the receiving site can do that you can't | C-CDA reason for referral (1..1) |
| Illness severity and current status | Stable, watcher or unstable; last vitals with time; current drips and devices | C-CDA vital signs (1..1); lets the receiver triage on arrival |
| Course so far | Presentation, working diagnosis, treatment given and response | 482.43(b) current course; EMTALA history, diagnosis, treatment |
| Active problems | Each with today's status | C-CDA problems (1..1) |
| Medications | Current list with last dose times; held drugs and why | C-CDA medications (1..1) |
| Allergies | Drug and reaction | C-CDA allergies (1..1) |
| Results | Key results with times; imaging reads, including preliminary ones | C-CDA results (1..1); EMTALA diagnostic studies |
| Pending results and tasks | What is pending, who will receive it, how it gets forwarded | EMTALA "as soon as practicable" clause |
| Code status and goals of care | Current status, who confirmed it, when | 482.43(b) goals of care and treatment preferences |
| Contacts | Sending physician's callback number; family contact; decision maker | So the receiver can ask |
| Consent and on-call record (ED transfers) | Transfer consent or certification; any on-call physician who refused or failed to appear | EMTALA 489.24(e)(2)(iii) |
Common failure: the summary describes admission day in detail and today in 1 line. The receiver needs the reverse.
Discharge summary
Reader: the primary care physician, the nursing facility, the next specialist and, more and more, the patient. When: at discharge; CMS requires the final diagnosis and a complete record within 30 days after discharge (42 CFR 482.24(c)(4)(viii)), but the receiver needs it before the first follow-up visit. Rule: 42 CFR 482.24(c)(4)(vii) requires a discharge summary with the outcome of hospitalization, the disposition of the case and provisions for follow-up care. The Joint Commission's heart failure certification measure ACHF-03 asks for a care transition record sent within 7 days that holds the reason for hospitalization, procedures, treatments and services, discharge medications with dose and indication, and follow-up treatment and services. Standard: the C-CDA Discharge Summary (LOINC 18842-5) lists allergies, hospital course, discharge diagnosis, plan of treatment, hospital consultations, procedures and results as 1..1, and says it should contain discharge medications.
| Field | What to write | Source that asks for it |
|---|---|---|
| Reason for hospitalization | Presenting problem and admission diagnosis | Joint Commission ACHF-03 |
| Discharge diagnoses | Principal first, then secondary, each with status | C-CDA discharge diagnosis (1..1); 482.24 final diagnosis |
| Hospital course | By problem, not by day; what was done and how the patient responded | C-CDA hospital course (1..1); 482.24 outcome |
| Procedures and consults | Each with date and key finding | C-CDA procedures and hospital consultations (1..1); ACHF-03 procedures |
| Key results | Admission vs discharge values for the labs that drove decisions | C-CDA results (1..1) |
| Results pending at discharge | Each test, who receives it, who acts on it | Missing from 65% of summaries in Kripalani 2007 |
| Discharge medications | Full list, marked new, changed, stopped or held, with reason and dose | C-CDA should contain; ACHF-03 dose and indication |
| Condition and disposition | Functional status and where the patient went | 482.24 disposition |
| Follow-up plan | Appointments with dates, and tasks with an owner | 482.24 follow-up care; ACHF-03; C-CDA plan of treatment (1..1) |
| Incidental findings | Each incidental finding and the follow-up the report recommended | The item a reader can't infer from the diagnosis list |
| Patient instructions and counseling | What the patient was told, in plain words | Missing from 90% to 92% of summaries in Kripalani 2007 |
| Code status and goals of care | Current status at discharge | 482.43(b) goals of care and treatment preferences |
Common failure: the hospital course is written as a day-by-day diary. Write it by problem. The reader wants to know what happened to the heart failure, not what happened on day 3.
Problem-list summary
Reader: anyone who opens the chart. When: kept current at every visit and every transition. Origin: Lawrence Weed's problem-oriented medical record, set out in "Medical records that guide and teach" (NEJM, 1968). Standard: C-CDA carries it as the problem section, required (1..1) in the Consultation Note, Transfer Summary, Referral Note and Continuity of Care Document.
| Field | What to write | Why it is there |
|---|---|---|
| Problem | A diagnosis if known, a finding if not ("anemia, cause not yet found") | Lets the list hold a problem before a diagnosis exists |
| Status | Active, resolved, inactive; better, worse, unchanged | A list without status ages badly |
| Onset date | Date or year first documented | Separates a new problem from an old one |
| Current plan | 1 line: what is being done and who owns it | Turns a list into a summary |
| Last reviewed | Date and by whom | Tells the reader whether to trust it |
Common failure: resolved problems never leave, and the list grows to 40 lines no one reads. Prune it at every annual visit.
Side by side: which field leads in which format
| Field | Pre-visit | Consult | Transfer | Discharge | Problem list |
|---|---|---|---|---|---|
| Reason or question | Visit reason | Leads | Leads | Reason for stay | No |
| What changed | Leads | Brief | Course so far | Hospital course | Status column |
| Current status and vitals | No | Exam | Leads | Condition at discharge | No |
| Medications with changes | Yes | As relevant | With last dose times | Full reconciled list | No |
| Pending results | Open loops | If you ordered them | Yes | Yes | No |
| Plan with owner | Care gaps | Recommendations | Tasks for tonight | Leads | 1 line per problem |
| Code status, goals | No | If asked | Yes | Yes | No |
Copy the fields into your own note with the templates, or see them filled in on a synthetic chart.