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“The longer the hospital course, the shorter the discharge summary.”

That’s what I was told Day 1 of my 1st rotation of med school - taken at face value that might seem a bit extreme… but there’s some truth to it. Let’s talk about it.

What’s the point of a discharge summary?

The writing

You’re going through discharge orders.

You see the patient’s home lisinopril was held.

Maybe this was done because the admission med rec was inaccurate. Or maybe it was simply forgotten. You think, “Sure, no reason I see not to continue it” and you hit the continue home med button.

But when reviewing details and writing your discharge summary, you realize this was held on admission due to hyperkalemia. You go back and discontinue it.

Bam. Medical error prevented.

Details like this are often overlooked because the discharging doctor is often not the one who cared for the patient from admission through discharge. Even if so, “small” details can be easily lost.

A source of that information is often your last progress note and is one of the reasons I recommend keeping every problem listed in your problem list.

Including the above in your progress note will ensure this detail isn’t lost and lisinopril isn’t accidentally restarted on discharge.

This is an example of how the process of writing a discharge summary is as important as the summary itself - reviewing the details of the hospitalization helps ensure accuracy in that crucial transition from inpatient to outpatient care. And that is one reason writing BEFORE discharge, rather than days or weeks after, is best for patients

Something is better than nothing

Something is better than nothing…that has two implications:

1. Get it done sooner, rather than later. The perfect discharge summary isn’t one that is perfect. A “good enough” discharge summary available for PCP follow up 3 days later is better than a perfect work of art 3 weeks later. Writing at the time of discharge when everything is fresh in your head is also quicker.

2. Does it get to the PCP? A dc summary that never gets to the PCP isn’t doing much good. Are the processes in place for your dc summary to get to the PCP? Are they automatically routed? Faxed? If the PCP is out of your system, perhaps printing and giving to the patient is best.

   This is one of the areas where open notes are a huge win. Apps like EPIC’s My Chart allow patients to have easy access to their notes when their own doctors may not have such access.

The Audience

I’ve mentioned this many times and will continue to say it: Many more people read your note than you realize 👇️ 

The above tweet was inspired by a tweet where I asked, “What should be in a discharge summary?” I expected mostly PCP’s but MANY different types of healthcare workers responded.

There are many insights to take away from that. But, among others:

• Your discharge summary impacts the care of your patient in more ways than you realize

• All of those people might judge you if your discharge summary is terrible and think highly of you if it’s complete, accurate and readable.

Headlines

Based on feedback I received from my tweet, I created the following template:

Some complained they “just wanted a punchline” and didn’t have time to read through paragraphs to find it. Including a “Discharge Diagnosis” gives them this “punch line.”

Others complained a hospital course had a lot of words but… never gave a diagnosis when simply “uncomplicated systolic heart failure exacerbation” would have given them the information they needed. Remember, you’re a doctor. You evaluated the patient. You made an assessment. GIVE IT here.

This also has coding implications - take a moment to give a final discharge diagnosis that perhaps wasn’t clearly specified otherwise.

If someone wants more detail, they can go to the hospital course. The key here is to be concise. Ask yourself, “Did this affect the overall hospitalization?”

One example I see often is day to day changes to pressors during a prolonged hospitalization. ICU transfer dates, how many pressors they required, intubation / extubation dates, etc would do the trick here. An unnecessarily detailed summary which isn’t read or understood because of its length is not a good discharge summary. “You can’t see the forest for the trees” as they say.

This bring us to an important question: are problem-based summaries better?

Narrative versus Problem Based

There was about a 50/50 preference to each by respondents. I will not recommend one over the other - do what comes easiest to you. Again, something is better than nothing.

I find stories much more impactful, so my default is a narrative. However, for longer hospitalizations, I will include a problem-based format in addition.

For the narrative, always include a concise WHY the patient presented to the hospital. Not a repeat of the HPI but a quick, “Patient presented with shortness of breath…” I recommend this because HPI’s also suffer from wordiness - so PCP’s waste time figuring out why the patient went to the hospital in the first place. (I wrote four newsletters on the HPI. This one is about story telling):

Transition to outpatient

The discharge summary is a vital key to the transition from inpatient to outpatient.

Including the headline “Medication changes” and including what medication changes were made and WHY helps this transition remain smooth and error-free. Do not rely on the auto-generated medication list - this can be confusing and doesn’t include the WHY.

Use dates, not relative terms. Example: If the patient is being discharged with long-term IV antibiotics, don’t say “IV Rocephin for 6 weeks.” Give the DATE of the last day of therapy.

Additionally, I include “Outpatient follow up needs”

This is where I list requested follow up appointments + requested follow up tests, pending studies that need following up and incidental findings. This is high-level communication to outpatient providers. Also, include the NAME of specialists if you know them / already established, as this is often unclear. Example:

Lack of follow up of incidental findings is a major area of lawsuit. You certainly want to ensure you do everything you can to pass along that information (it’s also good care, of course).

Review the final problem list

A patient is admitted with acute aphasia. The presumptive admitting diagnosis is a stroke. “Acute CVA” is listed as the problem. Below that problem is where the physician updates their daily plan.

But further work-up is negative for a stroke and is more consistent with a focal seizure. However, “Acute CVA” as problem is carried through to discharge. This could result in miscommunication to future providers and lead to a medical error. This will also likely result in a query to clarify since it has important coding and quality impacts. So, always review and update your problem list at discharge for accuracy. Specifically stating that a presumptive diagnosis was “ruled out” is preferred.

Where’s the patient going?

Additional headlines such as goals of care, weight-bearing status, social considerations, diet, etc. may be helpful if the patient is going to a post-acute care facility.

Be concise!

The central idea to that day 1 med school lesson was “Less is more,” and that was the MOST frequent comment in the replies to my tweet. Everyone is busy and conciseness is key. Again, this is done by using “headlines” as above and remembering the big picture when writing your summary.

Some write their discharge summary by adding a line every day to the hospital course. I find this results in lengthy summaries loaded with inconsequential details. This can be done well, but it must be cleaned up upon discharge. Think ESPN highlights, not the play-by-play.

Summary

To write the ideal discharge summary:

1. Do it before / at the time of discharge.

2. Use “Headlines” such as

   • Discharge Diagnosis

   • Hospital Course

     - Remember the big picture…ESPN highlights

   • Medication Changes

     - Include WHY

   • Outpatient follow up needs

     - Include the name of outpatient providers

     - Include incidental findings

     - Include requested follow up labs & pending labs at discharge

3. Consider additional headlines if going to post-acute facility

4. Review the problem list

5. Be concise!

That’s all for now. I hope that was helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

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