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Discharge summaries – don’t just copy and paste your notes!

Dr Victoria Phan BMed MD MClinUS DCH FPAA Cert, Risk Adviser, Member Advisory Services

Wednesday, 28 February 2024

Doctor discharging patient from hospital

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 repeat UECs.

GP to chase Swab MCS results. Please ring the laboratory between 9am and 3pm.

GP to follow up abnormal LFTs. Consider full liver workup and gastroenterology referral if concerned.

GP to follow up on 10 - mm 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 this paperwork, I have a perspective on what makes a useful discharge summary.

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.’

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 people leave the hospital without a summary and don’t receive it for days or even weeks.

But you need to remember that 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.

Top five practical tips

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 My Health Record and electronic discharges being transmitted directly to GP practices, patient’s health information is shared instantly. This means the GP’s contact details need to be correct from the start, especially from a privacy and confidentiality standpoint.

2. Provide concise and accurate information

Like most doctors, GPs are time poor and can easily miss the sentinel events in a 36-page discharge. A hospital audit found that approximately half of all discharge summaries were inaccurate or missing diagnoses.

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. A complex admission might warrant a longer summary, but it should only include the key events. Admission to ICU with a difficult intubation is helpful for future airway management, however details of noradrenaline requirement is probably excessive.

One of the main pieces of information we’d like is the patient’s current level of function and the status of their chronic conditions at the time of discharge.

3. Show a clear medications history

Medications are adjusted frequently upon admission and discharge. The hospital pharmacist may have reconciled the medications prior to discharge and can securely communicate the updated list to the patient’s usual pharmacist and GP.

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 imperative the list is accurate to ensure the continuity of their care. This is particularly crucial when discharging a patient to another institution such as an aged care facility or a jail.

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 can 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

Endless ’GP to chase’ statements can come across as condescending and are often unhelpful. 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 practitioner 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 tips 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 become part of the patient’s healthcare team.

More information

For medico-legal advice, please contact us on nca@avant.org.au or call 1800 128 268, 24/7 in emergencies.

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IMPORTANT:
This publication is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practise proper clinical decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published.

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