How to read a discharge summary

A discharge summary is written when you leave hospital. It is mainly written for the doctor who will look after you next, usually your GP, so it tends to be packed with abbreviations. Work through it one section at a time and check what the shorthand means. Most letters follow a similar structure.

The usual sections

Section	What it contains	Typical shorthand
Diagnoses	The conditions treated during the stay, sometimes with a code	Dx (diagnosis)
History	Why you were admitted and what you reported	Hx (history), SOB (shortness of breath)
Examination and findings	What the doctors found on examination, scans and tests	o/e (on examination), NAD (no abnormality detected)
Treatment and course	What was done and how things developed	Rx (treatment or prescription)
Medication on discharge	What to take, how much and when	TTO (to take out: medicines to take home), prn (as needed), bd / tds (twice / three times a day)
Follow-up	Checks, appointments, what the GP should do

Every abbreviation in the table is in the A-Z glossary, with its source. You can also paste the whole letter into the translator.

If your letter is in German

If you were treated in Germany or Austria, you will get an Arztbrief or Entlassbrief. German law requires the practice’s records to contain the history, diagnoses, examinations and findings, therapies and their effects, procedures, consent and information given, and doctors’ letters themselves (§ 630f(2) BGB). The letter usually has these parts:

• Diagnosen, often with an ICD-10 code such as “I10”. “V.a.” in front of a diagnosis means it is only suspected; “Z.n.” or “St.p.” means a past event, such as an earlier operation.
• Anamnese: your history as you told it.
• Befund: examination findings. “o.B.” (ohne Befund) and “unauffällig” mean nothing abnormal was found. AZ and EZ describe your general and nutritional condition.
• Epikrise or Verlauf: the summary of the stay and its interpretation. This is often the most useful part to read first.
• Therapie / Medikation: dosing is written as “1-0-1”, which means morning, midday and evening amounts: here one in the morning and one in the evening. “b.B.” means as needed.

What comes next

Under the European Health Data Space regulation, discharge reports are one of six priority data categories. Patients’ rights to access them electronically and free of charge apply from 26 March 2031. Until then, you can request a copy under the GDPR: see request your medical records.