Discharge Summaries
High-Yield Tips
- Modify the discharge summary based on what speciality you're rotating on, how important certain information is, how complex the admission was, how much time you have etc.
- In your plan, always include a safety net statement e.g. "if your symptoms worsen or you develop new symptoms (for example XXX), then please re-present to your local emergency department."
What is a Discharge Summary?
A discharge summary is a document that traditionally serves two purposes:
- It is sent to general practitioners to provide an outline of a patient's stay in hospital.
- It is given to patients to provide them with clear instructions on what they need to do in the short-term after being discharged from hospital.
In addition though, there is another major purpose to discharge summaries:
- To provide other hospital doctors (working at that hospital or other hospitals around the state) with background information about the patient.
Therefore, the information you provide in a discharge summary must be detailed enough for someone else who may come across the patient when they are unresponsive to have a clear understanding of what diagnoses they have, what medications they are on and what has happened during previous hospital admissions, but also be succinct for busy general practitioners to read through AND non-technical enough for patients to understand.
Clearly this means discharge summaries require more effort than a CMD + C & CMD + V from a note.
How to Structure a Discharge Summary
I structure my discharge summaries differently depending on what speciality I'm on, the complexity of the patient and their admission and how busy I am.
Additionally, considering what was discussed in the previous section, I put extra emphasis on the following:
- Introductory statement → this summarises the patient's presentation
- Plan
- I use no jargon in this section as this is the part I will circle (when handing the patient the discharge paperwork) and emphasise the patient must follow after being discharged.
- I list specific tasks that I want the GP to follow-up on, because otherwise GPs, understandably, get annoyed when the discharge summary simply says "follow-up with GP" with no information for the GP as to what they need to follow-up on.
- Medication changes → if any medications have been changed during the inpatient stay (including addition of new medications), I clearly document the new regime and the indication for changing the medication plan
- Investigations & imaging → since hospital doctors can check investigations on the computer system without reading through the discharge, I typically only include the most relevant investigations with significant findings throughout the patient's inpatient stay that would be relevant for the GP.
Here are a few typical discharge formats I would use for Medicine, Surgery & ED.
Medicine
Dear Dr XX [insert GP's name here],
Thank you for your ongoing care of XX a 56-year-old gentleman/lady who required an inpatient stay at XXX for severe community-acquired pneumonia.
HOPC
PMH (including surgical history)
MEDS
ALLERGIES
SOCIAL
(+/-) FH
ISSUES
(+/-) ***MEDICATION CHANGES***
PLAN
Kind regards,
XXX
Surgery
Dear Dr XX [insert GP's name here],
Thank you for your ongoing care of XX a 74-year-old gentleman/lady who presented to XXX with an infected ulcer on his right hallux.
HOPC
PMH (including surgical history)
MEDS
ALLERGIES
SOCIAL
(+/-) FH
O/E
IMPRESSION
PROGRESS
(+/-) ***MEDICATION CHANGES***
PLAN
Kind regards,
XXX
Emergency
Dear Dr XX [insert GP's name here],
Thank you for your ongoing care of XX a 23-year-old gentleman/lady who presented to XXX with abdominal pain.
HOPC
PMH (including surgical history)
MEDS
ALLERGIES
SOCIAL
(+/-) FH
O/E
IMPRESSION
PROGRESS
(+/-) ***MEDICATION CHANGES***
PLAN
Kind regards,
XXX