The Discharge Summary Why it matters and how to do it!

1. The Discharge SummaryWhy it matters and how to do it! BGSMC/VA IM Residency 2011-2012

2. 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

3. Introduction Diagnosis: Reason for admission Other Consultants Operations/Procedures Presentation 6. Hospital Course 7. Status at discharge 8. Medications at discharge 9. Discharge instructions 10. Follow up/ Pending labs Discharge Summary Contents

4. 1. Introduction • 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)

5. 2. Principal Diagnosis(s)…Why did they come to the hospital? “Health Care Acquired Pneumonia with hypoxemia and volume depletion”

6. 2. Other Diagnoses • All that required treatment and chronic conditions • Be as specific as possible • “Type 2 Diabetes Mellitus-uncontrolled” • Include • Functional-gait disorder or urinary incontinence • Cognitive-dementia • Behavioral-nocturnal agitation due to alzheimer’s • Affective disorders-depression

7. 3. Consultants • Consultants-Name and Speciality Dr. Felipe Gutierrez: Infectious Diseases Dr. Manoj Mathew: Pulmonary Dr. Barry Hendin: Neurology

8. 4. Pertinent Studies & Procedures • Includes: • CT Scans, MRI, other radiologic studies • ICU/tele monitoring, • Physical or Occupational therapy, Resp Therapy, etc. • Echocardiograms • Interventional or Surgical Procedures • IR instrumentation • Cath • Scopes • Taps What would be important to know as a PCP and difficult to track down?

9. 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?

10. 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!

11. 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

12. 8. Discharge Medications • Some argue it is the most important part of the discharge summary • Continued • Discontinued • Changed • New

13. 9. Discharge instructions • Diet • “2 gram salt, consistent amount of green leafy vegetables” • Activity • “home PT” • “Wheelchair bound” • Resume full activity when able to tolerate • Return to work/school • Return to driving • Wound Care Instructions • Other Instructions • Signs, symptoms, red flags and who to call • HF monitoring! • Medication side effects • How to reach the medical team

14. 9. Disposition • Where is the patient going at the time of discharge • Examples: • Discharged to: • Home • Home with hospice • SNF • Deceased

15. 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

16. 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

17. Introduction Diagnosis: Reason for admission Other Consultants Operations/Procedures Presentation 6. Hospital Course 7. Status at discharge 8. Medications at discharge 9. Discharge instructions 10. Follow up/ Pending labs 11. Questions? Discharge Summary Contents

20. Develop your WorkflowOptimize your time and effort! • Think about discharge as soon as patient is admitted • 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

21. Develop your WorkflowLearn 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

24. 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