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Discharge Summary Exercise
Care Transitions – Intern Orientation
During this section of the workshop, we will discuss a case in the context of a discharge summary. After
this session, you will be able to:
1. Generate a discharge summary with the elements most important to enhance safe medication
management and communication with other providers.
2. Generate a safe discharge medication regimen through demonstrating an understanding of the
importance of medication reconciliation.
3. Discuss the most important elements of patient and team communication at discharge.
Scenario:
You are re-admitting Mrs. Josephine Smith with another CHF exacerbation. Attached is the discharge
summary from her most recent hospital stay, including the medications prescribed at discharge. Prior to
her most recent hospitalization, she was taking the following medications at home:
Prior Home Medications:
1. Furosemide 40 mg once a day
2. Aspirin 325 mg po daily
3. Allopurinol 100 mg po daily
4. Donepezil 10 mg po daily
5. Calcium with Vitamin D, one tab daily
6. Escitalopram 10 mg po daily
7. Glipizide 5 mg po bid
8. Lisinopril 10 mg po qday
Task:
After taking three minutes or so to read the discharge summary, please perform the following tasks:
1. Consider what specific elements are less than optimal, as well as those that you think are most
appropriate. Concentrate in this instance on how the information is laid out and presented.
2. Please read the discharge medication regimen and consider what elements of medication
management were suboptimal, especially those that may have contributed to the patient’s
readmission. Compare patient’s prior home medication regimen (above) to those listed at
discharge (below).
3. Consider the discharge plan, including communication and follow-up. What elements may have
contributed to readmission, and what would you have changed in order to decrease the
chances of readmission?
Discharge Summary Exercise, Page 1 of 3
MEMORIAL HOSPITAL
DISCHARGE SUMMARY
DISCHARGE DIAGNOSES:
1.
CHF exacerbation
HISTORY OF PRESENT ILLNESS: An 82-year-old woman admitted to Grady Hospital with three days of
shortness of breath, cough, and orthopnea. She is usually seen in clinic at Piedmont Healthcare but the
ambulance brought her here from her home because it was the closest hospital. In the ER she was found
to have O2 sats in the 80s on room air and was put on nasal cannula oxygen. The chest X-ray found
pulmonary edema, and the patient was given Furosemide 40 mg IV, which helped her with her
symptoms considerably. She was then admitted to the medical floor for ongoing management of her
congestive heart failure.
PAST MEDICAL HISTORY:
1.
Congestive heart failure
2.
Moderate to severe tricuspid regurgitation.
3.
Mild Dementia
4.
Type 2 diabetes
5.
Bladder cancer
6.
Gout
7.
Hypertension
8.
Chronic kidney disease
ALLERGIES: The patient does have no known drug allergies.
ADMITTING LABORATORY STUDIES: Sodium 143, potassium 4.8, chloride 110, bicarb 22, BUN 35,
creatinine 2.5, glucose of 80. WBC 4.2, hemoglobin 11, hematocrit 34, platelets 289. CK of 72, troponin
0.03, BNP of 2190, alk phos 193, ALT 25, AST 26.
HOSPITAL COURSE: The patient was admitted with CHF exacerbation, showing normal blood pressure
but O2 sats in the 80s on room air and crackles on lung exam. She wasstarted on Lasix 40 b.i.d. IV. In
terms of her diabetes, Accu-Chek was ordered. Her medications were changed from lisinopril to
captopril for high blood pressure. The patient did have cardiac enzymes negative. A 2D echo was
checked which revealed that the patient has 15 percent EF with severe systolic dysfunction. She was
continued also on aspirin. BNP was repeated and went down from 2190 to 1174. On the day of
discharge, the patient’s furosemide was taken back to the home dose of 40 mg qday. Initially after
admission, Ms. Smith became quite confused with fluctuating mental status, but this improved after
diuresis, and by the time before discharge, her daughter did say that she was getting close to her
baseline mental status. She was also noted to have a urinary tract infection and she was given Levaquin
for an E.coli UTI. She came in on glipizide but was switched to glargine for ease of inpatient
management, which she tolerated well during her hospital stay. By the time of discharge she was able to
walk about 50 feet with no help, though she did get somewhat short of breath with longer distances.
The patient also developed an attack of gout and was given colchicine and prednisone.
She had worsening of her renal function which has improved. She also had afib with RVR that is now
rate controlled. Her family declined Warfarin therapy.
Discharge Summary Exercise, Page 2 of 3
CONDITION ON DISCHARGE: She was discharged hemodynamically stable.
ACTIVITY: She is to progress as tolerated.
DISCHARGE PLAN: The patient lives alone, so she will leave with home health services including
physical/occupational therapy and a homemaker. Her daughter plans to check in on her once daily
DISCHARGE MEDICATIONS:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Furosemide 40 mg once a day
Allopurinol 100 mg po daily
Aspirin 81 mg po daily
Calcium with Vitamin D, one tab daily
Lantus insulin 10 units SC QHS
Captopril 12.5 mg po tid
Lexapro 10 mg po daily
Donepezil 10 mg po daily
Prednisone taper
Discharge Summary Exercise, Page 3 of 3