The Discharge Summary Why it matters and how to do it!

BGSMC/VA IM Residency

2011-2012

Quality Summaries are…

• Higher quality when length < 2 pages

• Best in standardized format

• Ideally – PROMPT– SUCCINCT– PERTINENT– SPECIFIC

Modification of slide courtesy of Bill Lyons, MD; University of Nebraska

Discharge Summary Contents

1. Introduction2. Diagnosis:

– Reason for admission

– Other

3. Consultants4. Operations/

Procedures5. Presentation

6. Hospital Course7. Status at discharge8. Medications at

discharge9. Discharge instructions10. Follow up/ Pending

labs

1. Introduction• Identify yourself • Patient’s full name (clarify spelling)• MR number or Full SSN (VA) • Admission and discharge dates• Ward location (required at VA)• Expected co-signer: Attending who

discharged the patient with you• Others to receive document – all consultants,

PCP, outside subspecialists as needed (must include full name and fax number if not BGSMC doc)

2. Principal Diagnosis(s)…Why did they come to the hospital?

“Health Care Acquired Pneumonia with hypoxemia and volume

depletion”

2. Other Diagnoses

• All that required treatment and chronic conditions

• Be as specific as possible– “Type 2 Diabetes Mellitus-

uncontrolled”

• Include– Functional-gait disorder or

urinary incontinence – Cognitive-dementia– Behavioral-nocturnal agitation

due to alzheimer’s– Affective disorders-depression

3. Consultants

• Consultants-Name and Speciality

Dr. Felipe Gutierrez: Infectious Diseases

Dr. Manoj Mathew: Pulmonary

Dr. Barry Hendin: Neurology

4. Pertinent Studies & Procedures• Includes:

– CT Scans, MRI, other radiologic studies– ICU/tele monitoring, – Physical or Occupational therapy, Resp Therapy, etc. – Echocardiograms– Interventional or Surgical Procedures

• IR instrumentation• Cath• Scopes• Taps

What would be important to know as a PCP

and difficult to track down?

5. Presentation

• Be succinct!• ID, CC, HPI should be rolled into 1-3 lines• This is the one-liner you deliver to your

attending/team• DON’T include the whole physical! • You may include what they looked like when

they first arrived-abnl VS, PE, labs and how this contributed to your thinking?

6. Hospital Course

• Might be by problem if a complicated/long hospital course

• Include: – Main reasons for hospitalization– MAJOR ACUTE PROBLEMS– Chronic medical conditions requiring adjustments

TIPS:• Should be SHORT• If there was debate about the diagnosis then include

more discussion about the differential and ideas of consultants.

• Avoid narrative speech!

7. Function/Status at discharge

• “stable” is NOT enough!• Quantify in clinical terms the status of the

problems they came in with. • Abnormal labs (e.g. Cr, Hgb, LFTs, etc) or

vital signs• Document function for frail older patients and

ANY patient whose function– Is impaired at baseline– Declines prior to admission– Declines during hospitalization

• Some argue it is the most important part of the discharge summary

• Continued

• Discontinued

• Changed

• New

8. Discharge Medications

9. Discharge instructions

• Diet– “2 gram salt, consistent amount of green leafy vegetables”

• Activity– “home PT”– “Wheelchair bound”– Resume full activity when able to tolerate – Return to work/school– Return to driving

• Wound Care Instructions• Other Instructions

– Signs, symptoms, red flags and who to call– HF monitoring!– Medication side effects– How to reach the medical team

9. Disposition

• Where is the patient going at the time of discharge

• Examples:– Discharged to:

• Home• Home with hospice• SNF• Deceased

10. Follow Up/ Pending Tests• Follow up for the outpatient physician

– Pending test results (labs, path, radiology, or “none”)– Outpatient referrals to specialists– Physician of record for nursing home, home care, or

hospice orders? (contact MD prior to discharge!)

• Follow up for the patient– Next appointments– Outpatient diagnostic studies

OK, It’s dictated. Now what?

• Once it appears in notes, you make any necessary changes, then forward to attending (without signing)

• Attending reviews and signs

• It will now show up as “verified” and will sit in your inbox for your signature

Discharge Summary Contents

1. Introduction2. Diagnosis:

– Reason for admission

– Other

3. Consultants4. Operations/

Procedures5. Presentation

6. Hospital Course7. Status at discharge8. Medications at

discharge9. Discharge instructions10. Follow up/ Pending

labs11. Questions?

Develop your WorkflowOptimize your time and effort!

• Think about discharge as soon as patient is admitted– Barriers to discharge – Meds/DME– Follow up– Barriers to care– Outside resources

• Perform med rec accurately • Utilize discharge support M page• Use final progress note as discharge summary when

able• A team member should always contact PCP

– Brief summary– Fax number– Follow up appointment

Develop your WorkflowLearn it (and teach it) right the first time!

• Med rec required AT EVERY TRANSITION OF CARE

• Admission med rec requires an accurate home med list– Pharmacist– RN– You!

• Transfer med rec• Discharge med rec

Get Credit for Your Work

• Creating an accurate discharge summary will make you more likely to:– Bill and code correctly– Allow next provider to better care for

patient– Reduce readmissions– Reduce Depart workload– Reduce admission workload