1. Top information: at the top of the document, including hospital name, department, date and document title (such as "Discharge Record").

2. Patient information: provide basic information of the patient, including name, gender, age, hospitalization number, department, bed number, admission date and discharge date.

3. Chief Complaint: Describe the main reasons, symptoms and course of the patient's visit.

4. Past medical history: list the patient's past disease history, surgery history, allergy history and drug allergy history.

5. Diagnosis: Give the diagnosis results of patients, including initial diagnosis and final diagnosis. The diagnosis should be specific and clear, including the name of the disease, the severity of the disease and the relevant inspection results.

6. Treatment process: record the treatment process of patients during hospitalization in detail, including treatment plan, operation, medication, examination results, etc.

7. Reasons for transfer: explain the reasons why patients need to be transferred to higher-level hospitals, such as the need for higher-level treatment, equipment or technical conditions.

8. Transfer order: Give the patient a medical order after transfer, including medication, diet and activity suggestions, and the time of return visit, etc.

9. Signature: record the signature and date of the attending physician and the signature of the patient or family member to ensure the authenticity and validity of the record.