Transcript HOW TO write a good discharge summary

Jason Haag
Intern Conference
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Plan ahead
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Use Resident Assistants to
 Make follow up appointments
 On WebCis f/u lists
 Fax discharge summaries/patient information
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Plan ahead
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Talk to your patient
 How do they pay for meds?
 Who is going to pick them out?
 How long will the hospital stay be?
 Who do they live with at home?
 Do they have home health/home PT already in place?
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Start your discharge summary
Can put in procedures
 Secondary diagnosis
 Follow up appointments
 Pertinent labs
 Start the hospital course
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Brief Discharge Summary
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Most important take home message to patients
 Diagnosis
 what you have/had done
 Medications
 ***reconciled with home list***
 Discharge instructions
 What to do/what to look out for
 Follow up appointments
 Does not have to be exact date
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Talk with Social Worker
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Be very nice to these people…
About
 Ride
 They can provide one (ambulance, taxi, bus)
 Medications
 They can help pay for them (pharm assistance)
 Home Health/Home PT
 They can arrange it
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Talk with the Nurses
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Keep them in the loop
Nurses will provide
 Patient education
 How do I administer lovenox, do accuchecks?
 They will decipher your discharge summary into
patient talk
 Make sure they understand what’s going on with the
patient
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Talk with Home Infusion
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Talk early and often
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They provide home IV therapy
 Can arrange IV therapy on Saturday
 Can arrange acute changes in antibiotic choice
 IF they know about the patient ahead of time
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Communicate with PCP
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Don’t have to call
Send phone message with dx/tx
 Not a novel (they can read your d/c summary), just
give them a heads up
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TALK WITH THE PATIENT!!!!!!!!!
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They will have questions that they want their doctor
to answer
The more time you put in early in the day answering
questions will save you later
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Key Points
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Carry over all diagnosis
Reconcile medication list
Procedures/imaging
 No need to list every CXR, KUB
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Pertinent Labs
 Admission Chem-10, CBC
 Special labs
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Hospital Course
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List by problems
 Overview of hospitalization
 Not on HD#1…then on HD#2…
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Express the maximum amount of information in the
minimum amount of space
Be clear, concise, and coherent
 The longer it is, the less likely someone is to read it
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Must do Brief Discharge Summary
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To dictate or not to dictate
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+/- of dictation
If you start falling behind
They will find you…
 Medical Records keeps a log of physician of record and
will track you down for delinquent d/c summaries
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 If you are too delinquent they won’t let you work (i.e. won’t
pay you) till your caught up