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What’s needed and what’s not in a discharge summary

13 August 2019 | Dr Victoria Phan, Doctor in Training Medical Adviser, BMed MD, MClinUS, DCH, FPAA Cert, FRACGP, Avant

I am as guilty as the next person of producing a discharge summary that reads like this.

 Follow up with GP in 3 days.

 GP to chase Swab MCS results.

 GP to repeat UECs.

 GP to titrate INR.

 GP to follow up abnormal LFTs. Consider gastroenterology referral if concerned.

 GP to follow up on pulmonary nodule found on CT.

As an intern I thought how laborious it was to churn through endless discharge summaries, and start every letter “Dear Doctor, thank you for your ongoing care and management of this patient….”. I never stopped to think the GP knew them better than me, and I never considered how condescending it sounded telling them what to do.

Now I’m the GP receiving discharge summaries, this has made me think what actually makes a useful discharge summary?

Discharge summaries can be cumbersome and time consuming. For the JMO, in between attending ward rounds, consults, and assisting in theatre, discharge paperwork is generally of the lowest priority. On some rotations, there is such a pressure to discharge patients quickly that many patients leave the hospital without a summary and don’t receive it for days or even weeks.

The discharge summary may be the sole communication between the hospital and the GP. GPs rely on it to verify the patient’s history and help with continuity of care. The AMA’s position statement states “when a patient has received hospital care, the GP needs timely and comprehensive communication about the care provided, including transfer of care arrangements in order to enable the GP to continue providing high-quality care for the patient.”1

Practical considerations

     1. Plan the discharge from the beginning

Discharge planning for the patient should begin from admission and include early involvement of all allied health and community services. With the advent of My Health Record and electronic discharges being transmitted directly to GP practices, patient’s health information is shared instantly. Therefore it’s important the GP contact details are correct from the start, especially from a privacy and confidentiality standpoint.

     2. Provide concise and accurate information

A hospital audit found that approximately half of discharge summaries were inaccurate or missing diagnoses.2 A discharge summary should be a concise and accurate document of the major events. It should not be a copy-paste of all the progress notes and consults.

Like most doctors, GPs are time poor and can easily miss the sentinel events in a 36 page discharge. A complex admission might warrant a longer summary, but it should only include the sentinel events. Admission to ICU with a difficult intubation is helpful for future airway management, however details of noradrenaline requirement is probably excessive.

GPs would like to know what the patient’s current level of function and the status of their chronic conditions are at the time of discharge.

     3. Show a clear medications history

Medications are adjusted frequently upon admission and discharge. GPs want to know what medications the patient is currently taking, why medicines were stopped or started while in hospital, and when to restart the medications. Patients are generally only discharged with a three day supply, so it’s more imperative that the list is accurate to ensure the continuity of their care.

The hospital pharmacist may be able to reconcile the medications prior to discharge and securely communicate the updated list to the patient’s usual pharmacist and GP. This is particularly important when discharging a patient to another institution such as a jail or an aged care facility.

     4. Effectively share pathology and radiology results

Discharge summaries often list all the daily results and investigations. A detail of the final results and changes, prior to discharge is far more helpful. Include significant abnormal findings at the beginning of event summaries rather than buried amongst pages of investigations. Also, incidental findings on imaging results that require the GP to follow up should be noted upfront on the summary, so the GP won’t miss them.

Hospital teams frequently call other doctors to give verbal handovers for important tasks. The same approach should be adopted when discharging patients into the community. Consider phoning the GP to communicate important results, they will appreciate an update on major developments on the patient’s condition.

      5. Be specific in the follow up plan

Most GPs would agree that endless “GP to chase” statements can come across as rude and condescending. Consider the discharge summary as a letter to a colleague or your consultant, so use language that reflects this.

All actions, including specialist and allied health practitioners’ follow ups, should be clearly documented and contact numbers provided, where possible. It’s also important to communicate:

  • with the patient so they are made aware of the follow ups
  • the time frame for the follow ups
  • who is making the appointments
  • if the patient needs a referral letter
  • if community services have already been arranged.

Applying these practical considerations will ensure the GP receives a clear and concise discharge summary that will make the patient handover seamless and assist with co-ordination of care. This will also allow the GP to feel part of the patient’s healthcare team.

More information

Download our factsheet - Discharge from day surgery

Read our article - On the record: medical records and documentation

From onthewards - The inside scoop… How to write a discharge summary  

If you need further guidance, call the Avant Medico-legal Advisory Service on 1800 128 268.

References:

1Australian Medical Association, General Practice/Hospitals Transfer of Care Arrangements, 2018

2AusDoc.Plus, Half of discharge summaries inaccurate, 19 March 2016

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