Being discharged from the hospital is an important milestone in a patient’s recovery journey. However, the discharge process itself requires careful attention and planning to ensure a smooth transition from the hospital back home. A proper hospital discharge summary facilitates communication between hospital staff and the patient’s primary care provider, ensures continuity of care, and helps avoid unnecessary readmissions. This article will provide an overview of what a hospital discharge summary entails and why it is so vital for safe, high-quality patient care.
What is a Hospital Discharge Summary?
A hospital discharge summary is a document that outlines key details regarding a patient’s hospitalization stay and plan for continued care at home. The discharging physician or hospitalist prepares it when a patient is ready to leave the acute care setting. The discharge summary serves as a way to communicate important medical information to the clinicians who will be assuming the patient’s care after hospital discharge.
The discharge summary typically includes details such as:
- Patient demographics and contact information
- Dates of hospital admission and discharge
- Reason for hospitalization (chief complaint)
- Significant findings, test results, and procedures performed during hospitalization
- Final diagnosis and condition at discharge
- Discharge medications, including any new prescriptions
- Follow-up instructions for the patient, such as dietary restrictions, activity recommendations, or upcoming appointments
In essence, the discharge summary encapsulates the patient’s clinical status, hospital course, and care plan going forward for the benefit of both the patient and the post-discharge clinical team.
Why is the Discharge Summary Important?
A comprehensive, high-quality discharge summary serves several important functions:
Continuity of care – It provides critical information to the clinicians who will be taking over the patient’s care, such as the primary care doctor, visiting nurses, or rehabilitation facilities. This helps ensure continuity of care across healthcare settings.
Patient safety – It communicates medication changes, pending tests, and follow-up needs to avoid adverse events. This helps keep patients safe during care transitions.
Compliance – It is often required by payers and regulators to show medical necessity for hospital services. Complete documentation helps with insurance claims processing.
Legal record – It becomes a part of the patient’s legal medical record documenting their hospital stay, care received, and status at discharge.
Quality metrics – Details like discharge medications reconciliation can be quality indicators for hospital performance measures around care transitions.
In summary, the discharge summary has value on many levels – from the individual patient to the healthcare system at large. A high-quality summary facilitates optimal outcomes for each discharged patient.
Sections of the Discharge Summary
While discharge summary format can vary, most summaries contain the following key sections:
Patient information – Name, demographic details, contact information, healthcare proxy/POW holder.
Hospital course – Details regarding admission, significant findings, procedures, and treatment.
Discharge diagnosis – Final diagnoses and conditions treated during hospitalization.
Discharge medications – Updated medication list with new prescriptions. Comparison with pre-admission medications.
Discharge instructions – Specific instructions or orders for the patient to follow post-discharge. Guidance on signs or symptoms to monitor that require urgent follow up.
Follow-up plan – Recommendations for timing of follow up visits, referrals placed, pending tests and results to be reviewed later.
Discharging physician information – Name and contact information for questions.
Having structured sections makes the discharge summary organized and easy to navigate for clinicians and other readers.
Steps in Creating the Discharge Summary
Discharge summary creation is a process that begins at admission and culminates at the time of discharge:
Admission – Pertinent details are recorded about the patient’s presenting history and comorbidities.
During hospitalization – Clinically significant events, consultations, procedures, and diagnostic results are documented in the medical record.
Discharge planning – Pending testing and follow-up needs are identified by the rounding physician team. Discharge orders and prescriptions are written.
Summary dictation – The hospital physician creates a summary by gathering and dictating key details from the medical record into each standard section.
Summary review – content is reviewed for accuracy, completeness, and clarity. Any discrepancies or omissions are remedied.
Patient delivery – The final signed summary is delivered to the patient and transmitted to the follow-up care team.
Accurate, timely summary creation relies on synthesis of clinical details from the entire hospitalization. Beginning the process early ensures discharge is not delayed.
Best Practices for an Effective Discharge
What makes for an high-quality, effective discharge summary? Below are some best practices to keep in mind:
- Be thorough but concise – Include all clinically significant findings but avoid extraneous details. Stick to 1-2 pages in length if possible.
- Use plain language – Write in layman’s terms patients and families can understand. Define any medical jargon.
- Explain medication changes – Document medication reconciliations clearly and educate the patient on any new meds.
- Outline post-discharge instructions clearly – Providing actionable steps for patients to take helps prevent readmissions.
- Verify pending test results and follow-up – Document any forthcoming or missing test results and when the patient should have them reviewed.
- Include warning signs – Emphasize what symptoms warrant prompt medical attention.
- Use structured format – Organize summary information using consistent sections. This facilitates information retrieval.
- Deliver summary to patient – Ensure the patient receives a copy of the discharge summary for their records.
Following best practices for discharge summary creation promotes patient safety, care coordination, and positive outcomes during the critical post-discharge period.
Conclusion
In today’s complex healthcare system, a comprehensive hospital discharge summary serves a vital role in the continuity and quality of patient care. Meticulous, timely preparation of discharge summaries facilitates smooth care transitions, avoids preventable readmissions, and keeps patients safe. By understanding the components of a high-quality summary, patients and providers can work together to make discharge as safe and seamless as possible. As care becomes increasingly fragmented across settings, diligent discharge documentation enables all members of the care team to be on the same page.