We recently got asked, as a part of our hospital ethics committee work, is it ethical for a medical resident to complete a discharge summary for a patient they had not spent much time caring for? It seemed that the doctor who had been taking care of the patient is now on vacation.
Now, in my paid work as a Hospitalist, the ultimate person responsible for the discharge summary is myself, as the attending physician of record. Generally, the senior resident working with me, completes the discharge summary. It is expected that the summary of the hospital stay is completed within twenty-four hours of discharge. Occasionally, a summary will not be done and weeks from the patient’s discharge I will be reminded of this fact by our records office. Usually, I resent this; but more often than not, I find it interesting to go through the trajectory of a person’s hospital stay- what they came in with, who saw them, what sort of tests were done to them, what the results showed and finally- most importantly- what their primary care doctor or nurse practitioner needs to follow through so that the patient can be kept from harm or hospitalization.
I appreciate the chance to look at the care that my patient received and a reflection on whether we did the right thing for the person. Of course, my residents do most of the summaries, and they have the additional time pressure of getting it all done within a day of the patient leaving the hospital.
What makes a good discharge summary? Again, as often happens in healthcare, it depends on who you ask. If the discharge summary is meant solely for the patient’s primary care doctor (and lucky is the person who has a primary care doctor that they trust) then it is the synopsis of the patient’s illness, any medication changes and follow up of tests, procedures in the future. If it is meant for the patient, then it should have no jargon and should include all follow up procedures, appointments, tests to be done as well as medications changes, as well as what the person needs to do — daily weights (as follow up for heart failure management) or noting down blood pressure or blood sugars for other chronic disease management.
It is a really important document and yet, we in Medicine suffer from a strange, inexplicable verbosity. Most discharge summaries I read have little to commend them- poorly written, copy and paste documents, with little information for either the patient or their doctors to act on.
It is key that in medical school we teach students to be able to think about the patient in a complete, though succinct manner. No matter what our trainees do they need to be able to communicate to others about their patients in a concise, though accurate manner. The “note bloat” has to go.
Our EMRs also need to make typing a discharge summary easier. Our system is not particularly good, though I have nothing else to compare it with. As we get more finicky — at least, health insurance companies do — about hospital admissions, it is essential that our communication about our patients, both to themselves and their doctors gets better. For that we need to write better discharge summaries.