zkwan

Assalamualaikum and hello guys. Since i didn't know all of my viewers, it lil bit awkward for me to keep this blog 'alive'. Hehe. By the way, its ok then. This is my blog and this blog is not for "tatapan umum" =p

Well, being graduated from abroad medical school is not as proud as u graduated from local medical school. Really! Since our most beloved country is very tough and strict in documentation compared to abroad especially the country that i have learnt too much medical knowledge. After reading some experiences,heard some rumors  and  glimpsed at others fb comment, i think as oversea medical graduated we need to be more tougher than a stone. =). After having some discussion with some friend, it is worrisome that i didn't knpw so much about how to write discharge summary, referral report and etc.

So, to ease some burden in the future, it is better to have some idea about discharge summary and referral report before i'm starting to be hospital-servant :) .

10 contents of a discharge summary documents the patient’s hospitalisation which includes:

1. the reason(s) for admission
2. significant physical and other findings(e.g. brief clinical statement of chief complaint and history of present illness)
3. significant diagnoses and co-morbidities(example, Principal diagnosis: Cellulitis and gangrene, left foot and lower leg. Comorbidities: Diabetes mellitus, insulin dependent, controlled. Staphylococcus aureus coagulase positive septicemia. Urinary retention)
4. diagnostic and therapeutic procedures(example, Principal procedure: Amputation, left leg, above knee. Secondary procedures: Suprapubic cystostomy with permanent suprapubic drainage)
5. significant medication and treatments(medical and surgical) and patient’s response to treatment, including any complications and consultations
6. patient’s condition/status at discharge
7. discharge medications and all medications to be taken at home
8. follow-up instructions(patient education when applicable), to patient and/or family (relative to physical activity, medication, diet, and follow-up care)  including instructions for self-care, and that the patient/responsible party demonstrated an understanding of the self-care regimen
9. unless contrary to policy, laws, or culture, patients are given a copy
10. a copy is provided to the practitioner responsible for patient’s continuing or follow-up care

Reference: http://mrpalsmy.wordpress.com/tag/discharge-summary/

What do I think are the important aspects of a hospital discharge summary?

1. Include the  main diagnoses during the hospital stay
2. Include a description of the surgeries and procedures during the stay.
3. Include relevant radiology and blood work results.
4. Include a  list of the consultants and their subspecialty involvement.
5. Include a brief (that's key) summary of the complicating conditions and hospital events.
6. Include an accurate list of the medications on discharge, including as needed medications.  
7. Include a list of pending labs or studies and recommendations for further outpatient studies or labs.
8. Strive for one page or less.

In the last year or so we have been asked by our hospital transcription service to also dictate the patient's condition on discharge.  I've often wondered why.  Well, it  seems like the Joint Commission has mandated that six components be present for a discharge from an acute to a subacute care facility.  What are the six mandated  Joint Commission components for a hospital discharge summary?

1. Reason for hospitalization
2. Significant findings
3. Procedures and treatments provided
4. Patient's discharge condition
5. Patient and family instructions (as appropriate)
6. Attending physician's signature

Interesting.  I never knew one could regulate a discharge summary.  It's hard to imagine how one could define each component.  Is there a multiple choice we can click on?  It all seems so silly.  First of all, do they mean stable vs unstable?  Or are we supposed to document how badly they smell?    Or that they look especially ugly on discharge day.  Or perhaps the Joint Commission wants to make sure they are financially secure on discharge.  Or perhaps they mean IQ status.  Maybe they want us to document how good a father the patient is.  It just seems so confusing. 
Here are the real problems with the hospital discharge summary process.

1. Failure to dictate in a timely manner.  This is most commonly a problem with subspecialty services who take weeks upon weeks to dictate their discharge summary while the hospitalist has admitted and discharged the patient three times since their sentinel subspecialist admission.
2. Failure to include any relevant information.  When a physician assistant on the orthopaedic service dictates a hospital discharge summary on an 85 year old who spent 12 days in the hospital with a heart attack, acute renal failure and two cardiac resuscitations and dictates nothing more than the procedure name and random thoughts of the day, you know that no thought was put  into the process.  But then again, nobody gets paid less for a poor job, so why bother putting any effort into it?
3. Using English as your second language.  If your transcriptionist can't understand you, you have a problem.  Speak slowly so you don't get back a hospital discharge summary filled with medical transcription errors.
4. Dictations that are way too long.  This is a discharge summary of the hospital stay, not a minute by minute, hour by hour, day by day account.  If you are  too wordy in your discharge summaries you need to know that everyone hates you.  Nobody reads them except you.  Nobody thinks they are a masterpiece except you.  A summary is meant to be brief.  Make it brief.  Whenever I admit someone,  I pull up old records.  What are the only things I look at on the DC summary?  Diagnoses and discharge medications. Everything else is noise. Plus, it's expensive to pay someone to transcribe all that nonsense.  If someone really wants to get to the fine details, they can pull up the EMR comparisonrecords.
5. Failure to carbon copy the hospital discharge summary to the primary care physician AND other subspecialists taking care of the patient.  If they don't get your records, why bother with the summary at all?

Reference: http://thehappyhospitalist.blogspot.com/2010/04/my-shortest-hospital-discharge-summary.html