Hospital Discharge Summary: My Shortest One Ever.

What's your shortest discharge summary ever?  A hospital discharge summary is used to summarize the events of a hospitalization.  For hospitalist medicine, besides direct physician to physician discussion on discharge, the hospital discharge summary is the most important tool available to relay the events of the hospital stay to the outpatient primary care physician and other subspecialists on the case.

Unfortunately, the hospital discharge summary is often a pile of garbage.  What you get is highly dependent on the person who does it. Most physicians receive  very little medical training on how to dictate well.  It's trial by fire.  There are templates out there on how to do it.  But mostly you learn by repetition and experience.

As a medical student, I remember spending almost two hours one day dictating a hospital discharge summary for the resident.  I look back in horror at the day and wonder if anyone ever read it.  As an intern in residency, you start out worrying about getting everything into the discharge summary and hopefully by the time you are done with residency, you've become brief and succinct.  For some people, however,  that concept never sticks.  For others, they take it to the extreme.  Today, I do my hospital discharge summaries immediately on discharge 100% of the time.  They take me about five minutes to complete from start to finish, a far cry from my days in training. 

A hospital record, even if you are only admitted for one or two days can be twenty, thirty, forty pages  long or more  with electronic documentation from all the relevant hospital professionals.  Everyone has their own documentation in the chart from the nurses and respiratory therapists to the physical therapists, the emergency room physicians and the hospitalists.  

Never would I consider going through the electronic medical record page by page to decipher a hospital admission.  The hospital discharge summary is intended to give you the important summary of events. It should be the most important documentation in the chart.

Unfortunately, there is little standardization to the hospital discharge summary process across this country.  It's a highly stylized process based on the whims and feelings of the man or woman behind the dicta-phone.   What do I think are the important aspects of a hospital discharge summary?
  1. Include the  main diagnoses during the hospital stay
  2. Include a description of the surgeries and procedures during the stay.
  3. Include relevant radiology and blood work results.
  4. Include a  list of the consultants and their subspecialty involvement.
  5. Include a brief (that's key) summary of the complicating conditions and hospital events.
  6. Include an accurate list of the medications on discharge, including as needed medications.  
  7. Include a list of pending labs or studies and recommendations for further outpatient studies or labs.
  8. Strive for one page or less.
In the last year or so we have been asked by our hospital transcription service to also dictate the patient's condition on discharge.  I've often wondered why.  Well, it  seems like the Joint Commission has mandated that six components be present for a discharge from an acute to a subacute care facility.  What are the six mandated  Joint Commission components for a hospital discharge summary?
  1. Reason for hospitalization
  2. Significant findings
  3. Procedures and treatments provided
  4. Patient's discharge condition
  5. Patient and family instructions (as appropriate)
  6. Attending physician's signature
Interesting.  I never knew one could regulate a discharge summary.  It's hard to imagine how one could define each component.  Is there a multiple choice we can click on?  It all seems so silly.  First of all, do they mean stable vs unstable?  Or are we supposed to document how badly they smell?    Or that they look especially ugly on discharge day.  Or perhaps the Joint Commission wants to make sure they are financially secure on discharge.  Or perhaps they mean IQ status.  Maybe they want us to document how good a father the patient is.  It just seems so confusing. Regardless, I don't think the Joint Commission would find this original Happy ecard discharge process acceptable:

"Best Discharge Orders Ever:  Patient talking on phone with 12/10 pain.  Please have RN call her and discharge her ass by phone."

Best discharge orders ever.  Patient talking on phone with 12/10 pain.  Please have RN call her and discharge her ass by phone photo.

Here are the real problems with the hospital discharge summary process.
  1. Failure to dictate in a timely manner.  This is most commonly a problem with subspecialty services who take weeks upon weeks to dictate their discharge summary while the hospitalist has admitted and discharged the patient three times since their sentinel subspecialist admission.
  2. Failure to include any relevant information.  When a physician assistant on the orthopaedic service dictates a hospital discharge summary on an 85 year old who spent 12 days in the hospital with a heart attack, acute renal failure and two cardiac resuscitations and dictates nothing more than the procedure name and random thoughts of the day, you know that no thought was put  into the process.  But then again, nobody gets paid less for a poor job, so why bother putting any effort into it?
  3. Using English as your second language.  If your transcriptionist can't understand you, you have a problem.  Speak slowly so you don't get back a hospital discharge summary filled with strange dictation errors.
  4. Dictations that are way too long.  This is a discharge summary of the hospital stay, not a minute by minute, hour by hour, day by day account.  If you are  too wordy in your discharge summaries you need to know that everyone hates you.  Nobody reads them except you.  Nobody thinks they are a masterpiece except you.  A summary is meant to be brief.  Make it brief.  Whenever I admit someone,  I pull up old records.  What are the only things I look at on the DC summary?  Diagnoses and discharge medications. Everything else is noise. Plus, it's expensive to pay someone to transcribe all that nonsense.  If someone really wants to get to the fine details, they can pull up the EMR  records.
  5. Failure to carbon copy the hospital discharge summary to the primary care physician AND other subspecialists taking care of the patient.  If they don't get your records, why bother with the summary at all?
With that said, a short discharge summary is no problem at all if it includes all the relevant hospital information.  While signing off my electronic records the other day, I came across this hospital discharge summary, which I consider my shortest hospital discharge summary ever:
1. Drug overdose, Benadryl. 
 2. Suicidal depression.  
Labs fine.
Thirty-two year old suicidal female took a bunch of Benadryl and was EPCd.   No relevant issues. Safe to leave with no medications.
 And that's how you dictate the shortest  hospital discharge summary ever. 

Some of this post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk. 

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