A hospital discharge letter summarizes a patient’s hospital stay and provides instructions for follow-up care. As a healthcare provider, writing clear, thorough, and accurate discharge letters is an important part of the discharge process. An effective discharge letter facilitates communication between hospital physicians and the patient’s primary care provider to ensure continuity of care.
Introduction
A thorough discharge letter contains essential information about the patient’s diagnosis, hospital journey, procedures, and the plan for post-discharge care. The responsibility for completing this rests with the discharging physician or healthcare provider. While the specific format may vary among hospitals and healthcare systems, most discharge letters share common elements.
Creating a comprehensive yet concise discharge summary demands careful attention and time. Nevertheless, investing the effort to compose an effective discharge letter can enhance patient outcomes by minimizing readmissions and post-discharge complications. This article offers tips and best practices for crafting discharge letters that effectively convey crucial patient information, facilitating safe transitions of care.
Components of a Hospital Discharge Letter
An effective hospital discharge letter includes the following key components:
Patient Information
- Full name
- Date of birth
- Dates of admission and discharge
Diagnosis and Hospital Course
- Reason for hospitalization
- Significant findings from diagnostic tests
- Final diagnosis upon discharge
- Brief summary of care, procedures, and treatment provided
Discharge Condition and Instructions
- Condition of patient at discharge (stable, improved, etc.)
- Follow-up needs (e.g. appointments, labs, exams)
- Medications prescribed, including names, doses, frequencies
- Post-discharge instructions for self-care and restrictions
Pending Test Results
- Any test results still pending at discharge
- Plan for patient notification of results
Providers
- Names and contact information for all physicians who cared for the patient
- Name and contact information for the discharging physician
Summary
- Brief overview of the hospital course and highlights from the discharge plan
Tips for Writing Effective Hospital Discharge Letters
Follow these tips to create clear, thorough, and well-organized discharge letters:
Use a Template
Using a standardized template, either paper-based or electronic, can help ensure all essential information is included. Adapt the template as needed for patient specifics.
Be Concise
Good discharge letters are brief yet comprehensive. Use bullet points and avoid extraneous details. Focus on communicating the vital information concisely.
Use Simple Language
Avoid using complex medical jargon and abbreviations. Write in plain language for better comprehension by patients, families, and outpatient providers.
Include Specifics
Provide detailed information on discharge medications, upcoming appointments, pending tests, and post-discharge restrictions or instructions. Vague plans can lead to poor care continuity.
Summarize the Hospital Course
Briefly recap diagnosis, key tests, procedures, and treatment. This provides context for the discharge plan and facilitates follow-up care.
Check for Accuracy
Review the letter thoroughly prior to finalizing it to confirm all information is accurate and complete. Correct any errors.
Send Promptly
Send the discharge letter to the patient’s outpatient providers within 24 hours of discharge for timely follow-up.
Common Sections of a Discharge Summary
While discharge letter formats vary, most include sections similar to the following:
Patient Information
Full name, date of birth, admission and discharge dates
Chief Complaint on Admission
Primary symptom or condition leading to hospitalization
History of Present Illness
Overview of the illness and related symptoms leading up to admission
Hospital Course
Summary of diagnosis, key test results, procedures, and treatment
Condition at Discharge
Description of patient’s health status at discharge
Discharge Medications
Comprehensive list of discharge prescriptions
Discharge Instructions
Directions for self-care, restrictions, and follow-up appointments
Follow-up Plan
Pending tests, plans for notifying patient of results, follow-up appointments
Discharging Physician Signature
Signature of provider completing discharge summary
Conclusion
Writing effective hospital discharge letters requires time and diligence to accurately summarize key details about a patient’s care. Following best practices for organization, brevity, specificity, and accuracy allows hospital providers to craft discharge letters that promote safe transitions of care. By serving as a bridge between hospital and outpatient settings, a well-written discharge letter facilitates continuity of care and improves outcomes.
