Transcript Discharge Summary Instructions

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. Introduction
2. Diagnosis:
– Reason for
admission
– Other
3. Consultants
4. Operations/Proced
ures
5. Presentation
6. Hospital Course
7. Status at discharge
8. Medications at
discharge
9. Discharge instructions
10. Follow up/ Pending
labs
1. Introduction
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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 Mellitusuncontrolled”
• Include
– Functional-gait disorder or
urinary incontinence
– Cognitive-dementia
– Behavioral-nocturnal agitation
due to alzheimer’s
– Affective disorders-depression
3. Consultants
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Consultants-Name
and Speciality
Dr. Felipe Gutierrez:
Infectious Diseases
Dr. Manoj Mathew:
Pulmonary
Dr. Barry Hendin:
Neurology
4. Pertinent Studies & Procedures
• Includes:
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CT Scans, MRI, other radiologic studies
ICU/tele monitoring,
Physical or Occupational therapy, Resp Therapy, etc.
Echocardiograms
Interventional or Surgical Procedures
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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
8. Discharge Medications
• Some argue it is the most important part of
the discharge summary
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Continued
Discontinued
Changed
New
9. Discharge instructions
• Diet
– “2 gram salt, consistent amount of green leafy vegetables”
• Activity
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“home PT”
“Wheelchair bound”
Resume full activity when able to tolerate
Return to work/school
Return to driving
• Wound Care Instructions
• Other Instructions
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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:
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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. Introduction
2. Diagnosis:
– Reason for
admission
– Other
3. Consultants
4. Operations/Proced
ures
5. Presentation
6. Hospital Course
7. Status at discharge
8. Medications at
discharge
9. Discharge instructions
10. Follow up/ Pending
labs
11. Questions?
Develop your Workflow
Optimize your time and effort!
• Think about discharge as soon as patient is admitted
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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 Workflow
Learn 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