Tutorial: Building a Heart Failure Discharge Summary

Discharge summaries after heart failure admissions need to be clear, complete, and sent promptly. This tutorial shows you how to use an AI tool to produce a structured draft from a set of clinical bullet points — in under ten minutes.

The scenario: you are discharging a 74-year-old woman after a four-day admission for decompensated heart failure. She is pacemaker-dependent, has chronic kidney disease (CKD), and was admitted with worsening oedema and orthopnoea. She improved with intravenous diuresis and is going home on an adjusted oral regimen.

Step 1: Write your clinical bullet points before opening the tool

Do this away from the tool — on paper or in a blank document. For this example:

Admission:
- Woman, mid-seventies
- Background: HFrEF (heart failure with reduced ejection fraction) 
  EF 30%, dual-chamber pacemaker for complete heart block, 
  CKD stage 3b, type 2 diabetes
- Admitted with 4-day history worsening orthopnoea, bilateral 
  ankle oedema, weight gain 4kg
- Precipitant: likely dietary non-adherence over recent holiday period

Investigations:
- NT-proBNP elevated on admission, improved at discharge
- CXR: pulmonary oedema on admission, improved at discharge
- Renal function: creatinine mildly elevated above baseline on admission, 
  improved to near-baseline at discharge
- Echo: not repeated this admission, most recent 3 months ago stable

Management:
- IV diuresis for 48 hours, then converted to oral
- Furosemide dose increased from previous
- ACE inhibitor (Angiotensin-Converting Enzyme inhibitor) continued, 
  no dose change
- Beta-blocker continued, no dose change
- Mineralocorticoid receptor antagonist — dose held during acute phase, 
  restarted on discharge with lower dose pending renal review

Discharge plan:
- Heart failure nurse follow-up 2 weeks
- GP: renal function and electrolytes in 1 week, potassium level check
- Device clinic: pacemaker remote monitoring to continue
- Patient counselled on fluid restriction and daily weight monitoring
- Safety net: return if weight gain over 2kg in 2 days or increasing 
  breathlessness

Step 2: Open the tool and set the format

Open claude.ai or chat.openai.com and start a fresh conversation. Type:

You are helping a cardiologist draft a hospital discharge summary. 
I will provide anonymised clinical bullet points. Produce a structured 
discharge summary with these headings: Reason for Admission, 
Relevant Background, Investigations, Management, Discharge Medications 
(framework only — no doses), Discharge Plan, Actions for GP.

Use professional medical language. Do not add clinical information I 
have not provided. Do not include drug doses.

Step 3: Paste your clinical bullet points

Paste the bullet points from Step 1. The tool will produce a draft. Read this example of what it might produce:

Reason for Admission

This woman in her mid-seventies was admitted with a four-day history of worsening orthopnoea and bilateral ankle oedema, with a weight gain of 4kg. Admission was consistent with decompensated heart failure, likely precipitated by dietary non-adherence.

Relevant Background

Background medical history includes heart failure with reduced ejection fraction (EF 30%), complete heart block managed with a dual-chamber permanent pacemaker, chronic kidney disease Stage 3b, and type 2 diabetes.

Investigations

NT-proBNP was elevated on admission and improved at discharge. Chest X-ray showed pulmonary oedema on admission with significant improvement at discharge. Renal function showed a mild elevation in creatinine above baseline on admission, returning to near-baseline at discharge. Echocardiogram was not repeated this admission; the most recent study three months prior showed stable findings.

Management

The patient was treated with intravenous diuresis for 48 hours, followed by conversion to oral diuresis. Furosemide dose was increased from the pre-admission dose. Angiotensin-converting enzyme inhibitor and beta-blocker were continued unchanged. Mineralocorticoid receptor antagonist was held during the acute phase and restarted at a reduced dose on discharge, pending renal function review.

Discharge Medications

[Clinician to add specific drug names, doses, and frequency from medication reconciliation]

Discharge Plan

• Heart failure nurse specialist follow-up in 2 weeks
• Device clinic: pacemaker remote monitoring to continue
• Patient counselled on importance of fluid restriction and daily weight monitoring
• Safety net: advised to return or contact the team if weight gain exceeds 2kg over two days, or if breathlessness worsens

Actions for GP

• Renal function, electrolytes, and potassium level: please check within 1 week of discharge
• Continue current prescriptions as per discharge summary medication list
• If renal function has improved further, mineralocorticoid receptor antagonist dose may be uptitrated — please discuss with heart failure team before making any changes

Step 4: Review for clinical accuracy

Read the draft with your clinical eyes. In this example, you notice:

• The management summary is accurate
• The actions for GP section correctly flags the renal check and the caution about the mineralocorticoid receptor antagonist
• The discharge plan correctly includes the 2kg weight threshold you specified

What is missing: the specific drug names and doses. These are marked as a placeholder — which is correct. You add those now.

Step 5: Add drug doses and complete the medications section

In your clinical system, paste the draft and populate the discharge medications section from the medication reconciliation you have already completed clinically. This is the most important step and cannot be delegated to a tool.

Step 6: Check the safety net

Read the "when to return" guidance carefully. In this summary, the 2kg weight gain threshold over two days is correct for your patient. But check: does this match your heart failure service's standard patient guidance? If your service uses different thresholds, update the language to match.

Step 7: Verify the GP actions are specific and achievable

The GP needs to know: what to check, when to check it, and what to do with the result. Read the Actions for GP section from the perspective of a GP who did not see this patient. Is the request clear? Is the timing specific enough? Would you know what to do if you received this letter?

Adjust any action that is vague. "Please review the patient" is not an action. "Please check renal function and electrolytes within one week and contact the heart failure team if creatinine has risen further above baseline" is.

Step 8: Finalise and send

Add the patient's identifying details, the date, and your name and signature in your clinical system. Review the complete document one final time. Send.

What the tool does badly

The tool cannot check whether the follow-up plan is feasible in your service. A two-week heart failure nurse appointment may or may not be achievable given your service's capacity. The plan in the discharge summary must reflect a real plan you have made, not one the tool has generated.

It also cannot generate the medication reconciliation. The discharge medications section is left as a placeholder deliberately. Filling it with accurate doses is a clinical task you must complete yourself.

What to try next

Apply this approach to a post-AF cardioversion discharge summary, a valve disease clinic letter, or an outpatient heart failure review letter to the GP. The structure changes slightly for each document type. The method — clear bullet points in, structured draft out, you review and add the clinical judgement — stays the same.

Remember: AI is a helpful assistant, not a clinician. You make the call.