Just Do It
Get it done, at the moment of discharge—while you are writing the scripts, arranging follow up, etc. Not only will it be much quicker, but you are much less likely to make mistakes (meds, scripts, f/u). A discharge summary written 30 days after discharge is of no use to anyone as they’ve already had their f/u or their readmission, etc. The rule in most hospitals is dictation within 24 hours of d/c. Remember—Vow to never spend a moment of your days off/vacation dictating old charts!!
Beware of Verbal (or Cut/Paste) Diarrhea
“I am sorry I have had to write you such a long letter, but I did not have time to write you a short one”‐‐ Blaise Pascal ~1657
Just because you spent 3 weeks taking care of a patient does not mean the discharge summary needs to be 20 pages long. It must be readable, concise, and in a problem‐by‐problem format (and not a blow‐by‐blow account). Think about who you are writing it for and how much time they will have to read it and what information is really needed to care for the patient at the next site/clinic/etc. DO NOT cut/paste or read into the telephone the full admit H&P. Remember this is a SUMMARY. If someone wants the whole H&P or whole CT scan report, they can get it!
Remember your 7th grade English Teacher:
Before writing, think about who your audience is.
A PCP, a NH or rehab physician, or a specialist the patient will see for the first time are all going to want different information. Think about who is the primary audience for your discharge summary and highlight the information that will be most relevant. Put yourself in the shoes of the recipient—“What would I want to know if I was the next doctor taking care of this patient?”
Be OCD about The Discharge medication list
Errors with medication reconciliation are a leading cause of readmission to hospitals and adverse drug reactions. Never write “resume home medications”—you have no idea what the patient is really taking at home. Split the list up into new medications, changed medications, stopped medications, and continued/unchanged medications. Beware of EMRs—garbage in, garbage out. If the person who took the medication list at admit was incorrect, your medication reconciliation will be wrong (but look very official since it’s typed and in the computer!) Always confirm/review the final list with your patients!
Make sure your discharge summary gets there
This one is obvious, but most often forgotten. Your hard work is wasted if the person you wrote for never gets the summary in a timely fashion. If the f/u is within the system (eg, PCIM clinic or the VA), no worries. But many patients have physicians outside—for these physicians you have two options:
- Low Tech Option: Complete and print out 2 copies and give to the patients; tell them to give one to their PCP.
- High Tech Option: fax/e‐mail it yourself (This is not scut and is vital to patient care and follow‐up.
Imagine you getting a patient for post‐hospital f/u and have nothing other than, “They told me it was my heart and put me on some medicines.”)
Discharge Summary Checklist and Template
Parkland Hospital
Parkland Hospital and Health System Discharge Summary Guildelines
A discharge summary may be written by a fourth‐year medical student, a member of the House Staff or Allied Health Professional, but shall be signed by the supervising Physician Member and shall include:
- The reason for hospitalization;
- Brief and concise statement of history and physical;
- Course in the hospital, including significant findings, treatment and documentation of supplying information to the patient and/or his/her family regarding alternative treatment, the prognosis, and outcomes of care, including unanticipated outcomes;
- Condition on discharge;
- Final diagnosis including all relevant diagnosis and all operative procedures performed recorded without abbreviations;
- Physical activity, medication, diet and follow up instruction to the patient and family as appropriate;
- Final progress note: For newborns or women with uncomplicated deliveries, or for patients hospitalized for less than 48 hours with only minor problems, a final progress note may be substituted for the Discharge Summary. The progress note documents the diagnosis, patient’s condition at discharge, discharge instructions, and required follow‐up care.
University Hospitals
UT Southwestern University Hospitals Discharge Summary Requirements
A written or dictated Discharge Summary shall be entered in the chart upon dismissal. The Discharge Summary must include the following:
- Reason for hospital admission.
- Description of treatment rendered.
- Significant results and/or findings of tests performed, including infections and complications.
- Condition of patient at time of discharge, including references to instruction relating to physical activity, medication, diet, and follow‐up care. Condition of the patient should be stated in terms that permit a specific measurable comparison with the condition on admission.
- In the event the patient dies in the hospital, the summary will be labeled "death summary" and should include items I.1, I.2, and I.3, as above, plus the probable cause of death and a resume of the circumstances leading thereto. The death summary is to be completed within 48 hours of the patient’s death.
- The final diagnosis, including complications and surgical/diagnostic procedures, if any. If diagnostic procedures are pending, the final diagnosis shall be entered in the record by the physician as soon as feasible after being notified by University Hospital of the availability of the diagnostic reports.
- A final progress note may be substituted for the discharge summary in the case of a patient with problems of a minor nature who requires less than a 48‐hour period of hospitalization and in the case of normal newborn infants and uncomplicated obstetric deliveries.
