Download Discharge Summary Tutorial - 1.84 MB

Objectives
The fourth-year medical student will be able to
write a complete discharge summary which will
contain the necessary elements which contribute
to a smooth care transition.
Acknowledgments
Society of Hospital Medicine: Adaptation of their
discharge summary template
Lindsay Mazotti, MD and C. Bree Johnston, MD
for adaptation of elements of their presentation
on transitional care
Elements of Discharge Summary
Presentation on Admission
Chief Complaint
History of Present Illness (HPI)
PMH/Past Surgical History
Emphasis should be on keeping this
section succinct.
3-5 lines for HPI
Discharge Summary cont.
Medications on Admission
Important to list in order to compare to discharge medications
Admission Physical Exam
Keep brief
Focus on pertinent positives
Pertinent Admission Labs and Diagnostic Studies
Don’t list all labs!
Hospital Course
Should be the main focus of your discharge
summary
Should be divided by problem
Focus on:
Major acute problems
Important chronic medical conditions (i.e., DM)
Each problem should have only about one short
paragraph
Hospital Course
For example, in a diabetic
patient who presented with a
stroke:
Stroke:
The patient was found to have no
acute changes on non-contrast
Head CT, and because he
presented several hours after the
onset of his symptoms, was only
given aspirin on admission. Initially,
he had a dense, flaccid, right
hemiplegia with expressive aphasia.
About five days into his admission,
muscle strength improved to 3/5,
and he was able to say some words
and better understand language.
Neurology consultants gave him a
good prognosis for recovering most
of his motor and language function.
Hospital Course
For example, in a diabetic
patient who presented with a
stroke:
Diabetes:
His glucose levels were difficult to
control initially, with several random
readings in the 300-400 level.
Endocrine consult recommended
increasing his Glargine Insulin dose,
which helped fasting glucose levels
return to the 100s.
Hospital Course
Even when divided by problem, within the
sections should include:
Consultations
Treatments rendered with response
Medication changes
Pertinent new labs or diagnostic tests
Procedures performed
Complications
Next Sections
Code status/advance directives
Was there communication with Primary
Care Physician
Disposition
Important to specify new setting of care
Include VNA, rehab, SNF, hospital transfer, or
deceased
Condition at Discharge
Important to describe physical function and if there
is a change from baseline
Medications at Discharge
Probably the most important section for
accuracy.
Medication errors are common pitfall of care
transitions
Important to highlight medicines that were
stopped
Highlight which medicines were changed, and
which ones are new
All images in this document provided by Lavanet.