Editor: Catherine George
It’s your first day of internship and you step onto the ward. You’ve seen Grey’s Anatomy, House MD, Scrubs so you have some idea what you’re in for… Or at least you thought you did. A few hours in it doesn’t take long before you realise that you are underprepared for one of the most important responsibilities of your job. No, I am not talking about emergency tracheostomies, end of life discussions or inotropes. I’m talking about how to write a discharge summary.
As part of our local redesign group at our hospital, we were tasked with regularly surveying junior medical officers to identify key issues within the hospital system that can be improved. A recurrent issue interns raised year after year was a resounding dissatisfaction with discharge summaries.
It wasn’t just that discharge summaries were cumbersome, though this was undoubtedly a contributor, but rather that there was a lack of formal guidelines or education about what was required. This was made worse as interns moved through different rotations under different consultants and registrars with different expectations. This made it difficult for interns to form a clear picture of how to write a discharge summary.
Inevitably, this resulted in significant variability in the quality and length of discharge summaries. I personally have seen some discharge letters ranging from a single sentence to dissertations of Iliadic proportions. I recall my own magnum opus was 10 pages long! The former situation can indicate a loss of vital information. The latter likely implies time that could have been better spent.
In response to this, and backed by the executive of our hospital who saw this as a priority, we set up a subcommittee of over 12 interns, residents, and registrars. The subcommittee aimed to address the issue of what makes a good discharge summary in the hope of trying to establish some formal guidelines.
In this blog, I’ll share some of the key learnings from our efforts around how to write a good discharge summary.
Firstly, it’s worth revisiting the purpose of discharge summaries. Traditionally, we think of discharge summaries as a letter to the general practitioner (GP) detailing the events of a patient’s admission to the hospital. But discharge summaries also serve other functions and there are several components of the healthcare system that rely on them.
Emergency physicians are increasingly relying on previous discharge letters as reliable documentation of a patient’s medical history where this is otherwise not available. Consultants and inpatient teams from various hospitals likewise use it as a record of investigations and treatment a patient may have received at their own or other institutions. Even hospital administrators rely on discharge summaries to keep track of hospital activity and codes to ensure appropriate allocation of funding.
With this in mind, we decided that we needed to approach all the above stakeholders for our own project. So together with an enthusiastic group of interns and residents, we surveyed general practitioners, medical and surgical consultants, coding officers and emergency physicians. We asked them what they thought were essential components of discharge letters, what’s not important and what can be improved. Our findings are summarised in the sections below and can be used as a guide for how to write a discharge summary.
The overwhelming consensus amongst all the groups was that the more concise a discharge summary – the better. After all, most GPs working in a typically busy practice will not have time to rifle through all 10 pages of your discharge document. Indeed, as most senior consultants would tell you, discharge summaries used to be a hand-written single-page form filled in just as the patient was about to leave.
Overall, the feedback was that a discharge summary should be treated as a handover document – a synthesized narrative with only the relevant facts rather than several disparate details.
When asked what were the most relevant aspects of a discharge summary that should be included, there was some slight variation between the stakeholders but invariably what most agreed on was a focus on the discharge plan. In particular relevant pathology, appointments, and actions that GPs and other specialists are required to follow through on.
This is a handover summary distilled to its essence. So, the take-home message is that if you only have a few precious minutes to write a discharge letter – focus on the plan. But there were other essential items that recurred in the surveys that many thought were absolute requirements. These items include:
Amongst the responses were several other very useful suggestions on what the stakeholders thought was lacking from many discharges that should be included to improve their quality. Leaving out any of the ‘essential items’ mentioned above was immediately considered as room for improvement, and this was sadly encountered quite frequently by our stakeholders.
Below, I’ve included the general comments on what stakeholders and our resident team felt was often lacking and could be improved in discharge letters:
Every specialty has some disease-specific information that most consultants agree should be included in discharge letters. Not only because they were relevant to the current admission, but also to serve as a reference for future management. I have termed these ‘bonus specialty headings’. Each intern and resident should be mindful of these as they start a new rotation.
An effective way to find out what these are is to ask previous residents who have rotated through the term. Or ask registrars and consultants on that rotation. You may not think it, but they are just as invested in the quality of discharge letters as you are! Most good consultants will be more than happy to answer these questions. Just don’t wait until the end of the term!
To give a flavour of this I have provided some examples below, but these are by no means exhaustive.
Having established that most stakeholders agree that too much information can make a discharge worse, we asked them which areas in discharge letters could be downsized. The verdict – the presentation.
All stakeholders agreed that the presentation on admission should be limited to one or two sentences. Only salient aspects of the presenting history should be included. Likewise, only relevant examination findings and investigations should make it into the discharge summary. Sure, a normal neurological and PR exam in a pneumonia patient may be a sign of a thorough ED resident. However, if the patient did not develop a stroke or PR bleeding during the admission, this can safely be left out from the discharge summary.
Similarly, most stakeholders felt that investigation results (pathology, imaging, etc.) should only be included if they were significant and/or needed to be followed up.
Surgical consultants specifically felt that routine inclusion of social history is not necessary and should only be included if relevant. I.e. risk factors for illness or if there were barriers to discharge planning.
The importance of discharge summaries should not be understated. An admission to the hospital can be life-changing. Adding to that, an understanding of a patient’s health can often be wholly reliant on the adequate documentation of this event. It is amazing to think that this information rests with that single lowly-regarded discharge letter. And even more baffling that the great responsibility of creating this letter falls to the most junior member of the medical team.
It may not be as thrilling as an emergency airway. But realising that many components of the health system rely on this crucial document, from consultants to administrators, may go some ways to validating all those hours doctors spend on writing discharge summaries in their formative years.
Our small project also highlighted a need for more formal education in medical school and during the internship on how to write a discharge summary.
I’d like to thank all the members of the Royal Prince Alfred Hospital discharge summary group who were part of this project. A. Bagust, A. Clarke, A. Snir, B. Chen, C. Yang, E. Black, G. Boots, J. Paterson, J. Soares, K. Hulme, K. Hill, L. Wells, M. Naidoo, S. Mason, S. Murray, V. Korczak, W. Hoang, Y. Kamaladasa and Y. Kong.
matthew linksNovember 5, 2017 at 8:53 pm
Nice article! but there are some things from previous literature that are worth mentioning. The main one is information and psychosocial concers. Using oncology as an example: patient doesn’t know they have cancer, carers stressed , patient understanding is poor, patient told life expectancy is less than three months – these are critical issues that never make it into discharge summaries and the principle applies in other specialties. Tattersall MHN, Butow PN, Brown JE, Thompson JF. Improving doctors’ letters. The Medical Journal
of Australia. 2002 Nov 4;177(9):516â€“20.
Elie MatarNovember 10, 2017 at 6:07 pm
Hi Matthew, thanks for your comment. I completely agree with you that psychosocial issues are significant (sometimes the most significant) aspects of a patient’s hospital admission and this should be reflected in discharge letters for those patients. Such examples are not limited necessarily to discussions around diagnosis and prognosis but also to end of life discussions, family meetings, grief/anxiety reactions or other significant concerns raised by patients. As you mentioned these are not only relevant to oncology but are common across all specialties and certainly more relevant to general practitioners and patients than the transient hypokalaemia fixed with a few tablets of Slow K that seems to always make the ‘issues’ list. As an aside, I think this latter point speaks to the tendency of junior doctors (and some senior doctors) to gravitate towards the more comfortable ‘biological’ aspects of patient care which are emphasized in medical school and reinforced by the perverse bias of health-care funding allocation towards procedure- and pharmacological-based care. Perhaps by encouraging junior doctors to be cognizant of reporting the psychosocial issues in discharge letters it will not only translate to better continuity of care but may subconsciously prime them to be mindful of these issues more generally as they progress to senior positions and go on to deliver care in outpatient settings.
Jannine RigbySeptember 5, 2018 at 12:50 pm
Hi Elie, we are a regional hospital in Victoria and would if possible like to get a copy of the survey tool you developed or utilised. Would you be able to provide this to us? Thanks Jannine