A discharge summary is a note briefly describing the course of treatment a patient has received at hospital while under your service’s care. It includes: why the patient came in, Past Medical/Surgical History, Admission Diagnosis and Discharge Diagnosis (these can be different), Course of treatment in hospital. Its important because this discharge summary is sent to the family doctor who is coordinator of the patient’s care, so they know why the patient was in hospital, and what will happen once they leave. It’s also important if the patient returns to hospital, other health care providers can refer to your summary and understand why they were hospitalized previously.
The first discharge summary I completed was when I was in Neonatal ICU, it took me 1.5 hours to complete it (which is too long). I didn’t have the information ready beforehand, and was scrambling through progress notes, old orders, old discharge summaries and even investigations such as bl I know some clerks and residents (especially staff) who dictate without having to look at any information while dictating. Now, I take about 10 minutes for each discharge summary I do, or less. What seems to work for me now is to print the discharge summary outline, and fill beside each bolded statement the information pertaining to the patient.
Be clear, concise, organized and accurate! Don’t dictate a summary that looks like Peace and War.
How to dictate: You have to call the transcription service (usually an extension through the hospital), usually you state your name, your position, which doctor you are dictating for.
For example, Introduction: “This is John Smith, a Physician Assistant Clerk dictating for Dr. Doe. Patient name is Bill Grant. Chart number is 123475. This is a discharge summary.”
In a dictation, you have to “say the punctuation”, or else your discharge summary will be a huge running sentence. There is someone on the other end will be typing out what you say. Its very helpful for the person that is typing if you indicate difficult spelling of names, conditions and medications.
For example “New Paragraph Helen Smith is a 30 year old female comma who came in presenting with shortness of breath period She is followed by Dr. Groge spelt G-R-O-G-E period Her current medications include Plavix spelt P-L-A-V-I-X period“
Note: how you read that sentence is how you would say it word for word!
Make sure you learn how to use the dictation functions! Pause, Rewind, fastforward, and finishing dictations.
Here is the outline of a discharge summary, one of my attending physicians during my internal medicine rotation gave me this copy to help guide me:
Note: This is specific to internal medicine. Other specialty services such as Surgery will have different styles of discharge summaries.
Discharge Summary Outline
1. Date of Admission and Date of Discharge
2. Copies to all relevant Health Care Professional, Institutions – GP’s – MD’s who have consulted and will follow up
3. Admission Diagnosis
4. Discharge Diagnosis
5. Relevant Past Medial History & Past Surgical History
6. Discharge Meds & Doses (clearly tate dosechanges from admission meds and new meds) – Also include medications discontinued, with the reason
7. Course in Hospital a) History (clearly state reason for admission b) Investigations / Procedures c) Treatment/Surgery d) Consultants e) Areas of care (e.g. ICU, CCU)
8. Relevant Investigation / Procedures a) Echocardiogram b) Angiogram c) Pulmonary Function Tests d) Imaging e) Relevant Blood Tests (e.g. HbA1c if Diabetes)
9. Issues & Follow-up Instructions a) Outline follow up plans clearly including all appointments, investigations arranged, and to be arranged and no-medical follow up (CCA, physiotherapy, social work, etc.) b) Clear instruction on things to follow up after discharge and by who c) Clear plan for the family physician on all active issues