Discharge Summary

Who actually reads this

Most people write this as though it disappears into a drawer. It has at least five readers, and each wants something different out of the same document.

The primary care physician opens it two weeks later with the patient in the room and eleven minutes on the clock. She wants to know what you changed and what she now owns.

The next hospitalist opens it at two in the morning when the patient bounces back through the emergency department. He wants the story, the trajectory, and why you thought it was safe to send this person home.

The skilled nursing facility builds tonight's care plan from it, so they want functional status, diet, activity and the exact medication list. Your summary is often the only thing traveling with the patient.

The pharmacist doing medication reconciliation reads it as a list of deltas. Give her only a final list and she cannot tell whether the missing lisinopril was a decision or an omission.

And sometimes an attorney, three years later, out loud, to a jury. That reader wants to know whether you documented your reasoning or only your actions. See charting and legal risk for the rest of that argument.

You cannot write five documents. Write one that is complete, organized by problem, explicit about changes, and honest about what is unresolved.

The sections, one by one

For a longer template with discharge condition, patient instructions and disposition broken out separately, use the discharge summary note version.

The hospital course The part everyone writes badly

This is where discharge summaries go to die. The standard failure is a day by day recitation copied forward out of the progress notes.

Read that at two in the morning. Why did the creatinine rise? Did it come back down? What did the echo show? A day by day course records what happened to the calendar, not to the patient.

Organize by problem instead, in the same order as your diagnosis list, the way you organize an assessment and plan. Each problem gets one paragraph: what it was, what you did, how it responded, where it stands today. Numbers, not adjectives. "Improved" is not data. "Weight down from 94.5 to 88.2 kg" is.

Same hospitalization, same number of words, and now the next physician can act on it. Note the last sentence of each paragraph. Every problem ends where it stands today. That is the sentence readers are hunting for.

Medication changes Where the harm happens

Post discharge harm is overwhelmingly a medication problem. Somebody keeps taking the drug you stopped, stops the drug you started, or takes the home dose and the new dose of the same agent under two different names. A final list prevents none of that, because it does not say what is different.

Write the deltas in four buckets: started, stopped, held, dose changed, and give every entry a reason. The reason is what keeps the change from being quietly undone by the next person who sees the patient.

Name the drug and dose, not the class. Say why, in six words or fewer. And if you cut a dose because of an event, say so, or the outpatient physician will assume it was a typo and put it back.

Pending results at discharge

Almost every patient leaves with something unfinalized. A culture with no growth at 48 hours. A biopsy nobody has read. A preliminary imaging read that says "correlate clinically." These come back to a service that has already forgotten the patient exists.

Make the summary the handoff. Give pending results their own heading, never a clause buried in the course, and give every item a named human being who owns it.

Item, date, owner, and when it gets looked at. Then close the loop for real: tell the patient these tests are pending and write in the instructions to ask about them at follow up. A patient who knows to ask is the best safety net you have.

Follow up

"Follow up with PCP in 1 to 2 weeks" is not a plan, it is a wish. A usable follow up line has four parts.

1. The name. An actual physician, not a service. If they have no primary care physician, say so and say what was arranged instead.
2. The interval. Tied to the risk, not to habit. A heart failure patient on a new diuretic dose is seen in seven days, not a month.
3. The phone number. Written in the document. The patient loses the paper and the facility will not know who to call.
4. The purpose. What that specific visit must accomplish.

A complete discharge summary example

Here is the whole thing on one patient, start to finish.

Discharge summaries and readmission risk

The most important thing about a discharge summary is not its contents. It is its arrival time. A perfect summary dictated eleven days out is useless, because the follow up visit already happened and the primary care physician sat through it with nothing but the patient's memory of what you changed.

That is the mechanism behind most preventable bounce backs. Not a missed diagnosis. A patient who kept taking the diltiazem you stopped, or never got the potassium checked, because the person in clinic did not know either was supposed to happen.

Finish it the day the patient leaves, and make sure it reaches the receiving physician instead of sitting in a chart nobody outside your system can open. If they are going to a facility, the summary and the medication list travel in the packet with them.

Before you sign

Run this list. It takes ninety seconds and catches almost everything.

• Do the discharge diagnoses match the problems in the hospital course, in the same order?
• Is the course organized by problem, and does every problem end with where it stands today?
• Are medication changes listed as started, stopped, held and dose changed, each with a reason?
• If they go home on an anticoagulant, are the indication, dose, duration and monitoring owner written down?
• Does every pending result have a named person and a date it gets reviewed?
• Does every appointment have a name, a date, a phone number and a purpose?
• Are discharge vitals and labs in there, with a date and time?
• Are diet, activity and disposition specific enough for a nurse who has never met this patient?
• Did you copy anything forward that is no longer true?
• Would you be comfortable if this were read aloud in a deposition three years from now?

Ten yeses. Sign it and send it today.