How to write a discharge summary

General Principle:

A discharge summary should not be too lengthy. I should however, be informative to the outpatient provider and during future admissions.

Outstanding issues

  • Labs that need to be ordered / followed up on, either by the primary care provider or a the Nursing Home:
  • The patient should have a Hct and Cr rechecked in 2 weeks
  • Provide Instructions to the Visiting Nurse; be specific:
  • Please weigh patient every day. Call MD at xxx-xxx-xxxx if 5 lbs over y weight.
  • List appointments that need to be scheduled; Give MD / subspecialty and contact info.

HPI

  • Do not copy from H&P. Instead, write a small paragraph that summarizes the reason for admission.

PMHx(can copy forward from H&P if you have already put this information in previously)

  • Give the pertinent information along with concurrent diagnoses:
  • CHF (EF 30% in 4/05)
  • CAD with h/o 3 MI’s in 1991, 1995, 2000
  • CAD (70% LAD lesion diagnosed by cath at Brigham in 4/07)
  • HIV (CD4 317, VL < 75 in 5/07)

Meds

  • Copy list from Logician after performing medication reconciliation

Hospital Course

  • Start with what happened in the ED:
  • In the ED, the patient’s vitals were…
  • In the ED, the patient was given…
  • Mention labs here or in the next section (mention here if the ED management was related to lab values, e.g. Kayelexlate given for hyperkalemia). It is helpful to mention baseline values if the values are abnormal or changed from previous. Initial labs were significant for_____. E.g. K 6.7, Cr 2.4 (baseline Cr 1.5-1.7), Hct 24 (baseline 30 in 4/07), BNP 967.
  • Mention studies here or in the next section (mention here if the ED management was related to study results). Initial studies were significant for _____.CXR with bilateral pleural effusions, EKG with TWI in II, III, aVF (which were unchanged from previous.)
  • Move onto what happened on the floor. If patient had complicated hospital course, go by problems. Otherwise if it was a short hospitalization with only 1-2 medical issues, just describe the events in chronological order.
  • On arrival to the floor, the patient’s vitals were…
  • Physical exam was notable for… (onlypertinents).
  • You can also talk about initial labs & studies here if not already in the ED portion.
  • Describe initial management. The patient was given 80 mg IV Lasix with adequate response.
  • Describe continuing management. Cardiomyopathy was consulted and recommended …, which was started (or not started because ...)
  • For each intervention, say how the patient responded. The patient was transfused 2 unitspRBC with a resulting Hct bump to 29.6.
  • Describe what you did for each of the patient’s presenting complaints, even if not related to the primary issue that the patient was hospitalized for e.g. The patient mentioned while in-house that she had fallen on her arm a week prior. Xray of left arm revealed no fractures.
  • Address all abnormal labs and studies, and give working explanations.
  • For patients with recurring issues, e.g. pain control issues in sickle cell patients, it is helpful to include their specific pain regimen while inpatient, e.g. The patient was started on morphine PCA at 2 mg/hr basal rate with 0.5 mg q15min. Pain was well-tolerated on this regimen.

Discharge Condition

  • Write the pertinent information you would want to know if you were the outpatient MD seeing the patient again 2 weeks after discharge. For example:
  • In hypertensive urgency, give discharge BP (or 24 hr range)
  • In CHF, give discharge weight
  • In COPD, give ambulatory sat
  • Again, address pertinent abnormal labs and studies. K on discharge was 4.0.

Lastly:

  • Think ahead: start summaries early for patients w/ complicated hospital courses – as early as day #2 if you can foresee a several day stay.
  • Summarize! Don’t give a play-by-play of each day.
  • Remember that it is not just other BMC residents who read your summary! Your summary gets faxed to PCPs and VNAs who try to decipher what your abbreviations mean and who actually have to carry out your instructions. Avoid abbreviations.
  • Patients and their caretakers may read the discharge summaries – be careful how you word things.