Discharge Summaries

Discharge summaries are something you obviously do again and again and again as a junior doctor, but I wanted to highlight their importance. After all the assessments, investigations, analysis and specialist opinions this is usually the only thing patients leave hospital with. They aren’t privy to the conversations that doctors have had. They usually can’t interpret their test results. They often forget what you or another doctor told them because of medical jargon and because everyone’s in a hurry.

In Emergency, discharging a patient is usually more difficult than admitting them because you need to make sure that they are safe to go home and that they know when to come back to hospital. A good discharge document is the difference between a patient who is empowered and educated and a patient who is unsure and unprepared for the next steps.

Before I tell you what a good discharge summary is I want you to think about who a discharge summary is for. I believe that a discharge is as much for the GP as it is for the patient. It’s a record of what happened. It’s the story of their care. If they can’t explain what the doctors did in hospital, then their discharge letter is the only thread of continuity between all your hard work and the patient’s usual GP.

What to Write

I have no proforma for what you should write, and I genuinely think that relying too heavily on a proforma will cause you to make errors or include far too much irrelevant information. The patient needs to understand your impression and the next steps. The GP needs to understand the course of their visit to Emergency.

I write a letter in full sentences like a clinic letter. Others use lists or dot points. Either is fine as long as you communicate the key facts:

• What was the patient’s presenting complaint

• What considerations did you make? The history, relevant negatives, relevant examination findings and pertinent investigations. Include a summary only.

• After all of this, what was your impression? What were they treated for?

• Were they reviewed by any specialist teams? What was there advice?

• What are the next steps?

• Under what circumstances do they return to hospital?

An Example

Here’s an example that I made up.

Dear Dr Who,

Thank you for your ongoing care of Mrs Wellington, a 75 year old woman who presented to the Emergency department after a fall. On arrival she was found to be in atrial fibrillation with a rapid ventricular rate running up to 150 bpm. She was febrile to 38.1. Her vitals were otherwise between the flags. In the last 3 days she has had symptoms of progressive shortness of breath with a productive cough. She has no history of atrial fibrillation and is independent from home with her husband. Her examination revealed crackles at her right base and a chest xray confirmed a right lower zone pneumonia and small associated pleural effusion. She had no other associated injuries and a CT brain showed no intracranial bleeding. Her bloods were reassuring with a WCC of 12, a CRP of 43 and normal electrolytes and renal function. She was treated with IV fluids, ceftriaxone and azithromycin before staying overnight in our short stay unit.

In the morning she had no further fevers and had reverted to a sinus rhythm running at 78 bpm. She was reviewed by our Cardiology team who started her on regular apixaban and was discharged home with the following plan.

Plan:

1. For pain relief take Paracetamol 1000mg (2 tablets) up to four times a day for fever.

2. Continue Augmentin Duo Forte 1 tablet twice a day for 5 days to treat your pneumonia

3. Continue Apixaban 5mg twice daily

4. Please see your GP in the coming week for a review. GP to kindly refer to Cardiologist Dr Thump for outpatient follow-up

5. Please arrange an appointment with Dr Thump for 4-6 weeks’ time. You will require a TTE (echocardiogram) before your appointment.

6. If symptoms worsen, such as chest pain, worsening shortness of breath or further falls, please represent to Emergency

Attached below I include the full panel of bloods and the chest x-ray and CT brain report without the pre-amble (which can contain sensitive information).

Do not forget to read the entirety of every radiology report. Incidental findings are often included in the body but not the conclusion. They are not usually relevant to the patient this moment, but they may need follow-up that we have to arrange.

I will give the patient this discharge with a patient information factsheet when possible. I also make the plan in bold and go through it step by step with each patient and tell them what symptoms they need to worry about and when to come back to Emergency without waiting.

The example above is one style. Perhaps I could make things clearer by including her diagnoses and impression in a separate line or by using dot points. Other doctors will tell you to write things differently or will use a different structure. You need to use a style that works for you, but I hope above I’ve illustrated the important bits. Another doctor should be able to follow the story of their stay, understand their diagnosis and treatment and understand clearly what the next steps are.

The Dos and Do Nots

I have read many interns' discharges in the past and there are patterns of poor writing that I want to highlight. My aim is not to be mean or critical but rather to help avoid some common pitfalls.

Do not copy and paste your own, or someone else’s, medical note. Don’t do it. Medical notes are not written for patients nor are they summaries of their care. I have seen my entire emergency note copy and pasted into a discharge summary days and days after I wrote it. I find this bizarre because if I have admitted the patient then their diagnosis has doubtless changed or become more specific. Why include the initial, now outdated, impression? My document is time-sensitive and justifies my actions at that point. The time has now passed. GPs are incredibly time poor. Why make them read something that is now irrelevant?

Do not include unimportant and sensitive information that the patient then reads. Many complaints have been made because erroneous and hurtful detail was included in the discharge summary.

Do make your instructions to patients as specific as possible. When giving vague advice patients may ignore important symptoms. Or they may overemphasise symptoms that you expected to continue, like pain. Illustrate the path ahead for a patient as best you can.

Do include an impression of what happened. I can’t tell you how many times I’ve read a discharge summary and wondered “but what did they think was wrong with the patient??”. No-one is a mind reader. Be explicit.

Do not assume a benign diagnosis if you’ve excluded the bad ones. A lot of people will write “possible gastritis” in chest pain patients when they’ve ruled out MI, PE, etc. But they don’t have any evidence of gastritis. This false assurance can be dangerous. If you think that that may be what’s happening, then outline the next steps like an H pylori breath test or a gastroscopy that the GP organises. If you aren’t sure what’s happening, tell the patient and write it down. Then if things get worse, they’ll come back.

Alright that’s enough of that. I hope some of this helps you write better discharge summaries for the patients you see.

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