Discharge Summaries Make a Difference

My husband was speaking in Maui at the beginning of March 2020, and I came down with COVID-19 on the airplane. After a serendipitous dinner with his brother, who lives in Dallas, I was quite ill, and my infection limited our activities. The weather was delightfully tropical. On our last day in Maui, we went whale watching, which was spectacular. We saw a collection of approximately 15 whales, which swam under our boat. Erick got miserably seasick, which threatened our flight to Oahu. There, we had a somber visit to Pearl Harbor, punctuated with about 10 glorious rainbows. Our penultimate day, we did an island tour.

You just read a summary of my vacation. I condensed the entire encounter of 10 days into eight sentences. Did you get enough information about the trip?

It depends what you are going to use the information for. If you are just being caught up on my travels, sure. Are you going to try to replicate our itinerary and activities? Then, no. If I had journaled our adventures, there would have been more specifics I could have shared with you, if you were so inclined to read them. Where we went, how much it cost, what we saw. However, if your trip was scheduled two weeks after mine, but you didn’t receive my trip summary until a month later, it wouldn’t be at all helpful.

Why do providers generate a discharge summary? The short answer: because they have to. It might be even more important to determine what the provider perceives a discharge summary is for. If they think it is busy work, and just fulfilling the directive of some administrative body, then the quality might suffer. If they believe it is valuable communication of the patient encounter for the follow-up physician and anyone else who might be reading it, then it is more likely to be detailed and illuminating.

Discharge summaries have elements mandated by the Joint Commission:

1. Reason for hospitalization (patient presented complaining of fevers, rigors, and cough);
2. Significant findings (physical exam demonstrated hypoxemia and confusion. CXR demonstrated a large RML pneumonia and blood cultures grew out Streptococcal pneumoniae. Diagnosis: Sepsis due to S. pneumoniae pneumonia with hypoxemia and metabolic encephalopathy);
3. Procedures and treatment provided (supplemental oxygen, intravenous fluids, and ceftriaxone administered. Sepsis protocol followed and infectious disease consult obtained. Sepsis resolved on Day 2.);
4. Discharge condition (discharged in improved and good condition);
5. Patient and family instructions (finish course of antibiotics, follow up with PCP next week, and return to ED for shortness of breath or concerning symptoms); and
6. Attending physician’s signature.

It strikes me that the mandated elements are sparse. If I had determined the required elements, I would have explicitly included the hospital course, outstanding issues of which the follow-up professional needs to be aware, and a list of final discharge diagnoses.

The Transitions of Care Consensus Conference (TOCCC) attempted to develop standards for transitions of care from the inpatient to outpatient setting. They also recommended the following elements, which would be included in the “ideal transition record,” and isn’t that what a discharge summary should be?

• Patient’s cognitive status;
• Emergency plan, person and contact number;
• Treatment and diagnostic plan, including a current, reconciled medication list;
• Prognosis and goals of care;
• Advance directives, power of attorney, consent;
• Planned interventions, durable medical equipment, wound care, etc.;
• Assessment of caregiver status; and
• Inclusion of the patient and caregivers in the development of the transition record to take into consideration the patient’s health literacy, insurance status, and cultural sensitivity.

Some of these seem more appropriate for the transition to another institution (e.g., skilled nursing or assisted living facility) than to home, but the essence is: provide the information that will be useful for the receiving clinician and/or institution.

The literature focuses on the need for aftercare providers to receive information, and on medicolegal considerations. It fails to mention that coders and billers also rely on accurate, complete, and timely discharge summaries. On the inpatient technical side, diagnoses are eligible for coding if they are present at the time of discharge or demise, and the discharge summary represents the prime and final opportunity to record diagnoses destined to be coded. My philosophy is that a correct and complete set of discharge diagnoses can be used to reconstruct the entire patient encounter. This ensures that the patient lands in the appropriate Diagnosis-Related Group (DRG) and the correct tier, for reimbursement.

Many institutions have templates for necessary components of a discharge summary. To design the ideal document, involve the appropriate parties. This should, at very least, include the people who will be generating the document and a representative of the folks who will be relying on the document, post-discharge. Compliance should ensure that the mandated elements are included. Information technology needs to be present to determine how to operationalize the endeavor.

If it were possible to start generating upon admission a discharge summary that could be finalized, dated, and inserted in the appropriate location in the medical record upon discharge, I would support that. It could be leisurely composed in a stepwise and thoughtful fashion.

At admission, the chief complaint and a brief history of present illness could be introduced. As the patient encounter progressed, the hospital course could be recorded in real-time. Each day, a sentence or two could be added, with revisions of the previous days’ entries for accuracy and clarity.

(e.g.,
Day 1: Awaiting ID consult.

Day 2: ID consult considering necrotizing fasciitis. Ordered CT scan.

Day 3: ID consult ruled out necrotizing fasciitis when CT scan did not reveal gas in soft tissue.).

A running summary could serve dual purposes; in addition to ultimately being inserted as the synopsis for the discharge summary, it could also inform caregivers during the encounter. If a patient crumps, the provider doesn’t have the time or inclination to read the entire chart – they just want the down and dirty, which will help them care for the patient right now. A concise running summary would be just the ticket.

When I was a physician advisor, we implemented an electronic summary. It drew in elements from multiple already established electronic sources to try to minimize duplicative effort. It pulled in the current medications from the MAR (medication administration record), and the provider could notate which ones were indicated for homegoing. It imported recommendations for physical and occupational therapy.

If labs or other tests were pending or scheduled, it recorded them. It was (and probably still is) very useful and timesaving. My contribution was to create a radio button that the provider had to click, which indicated whether the patient had expired. If so, it prevented the discharge (now, death) summary from including homegoing medication and instructions and follow-up appointments, now unnecessary and misleading.

Having the ability to construct a discharge summary rapidly from different sources can result in disjointed information if no one ensures that it is edited, revised, and accurate. It can, however, also result in a discharge summary being promptly available for review. Maybe it will be an opportunity for artificial intelligence (AI), to ensure that the narrative reads fluently.

Consider surveying your end-users (e.g., PCPs, nursing home providers) as to whether the data delivered to them was complete, succinct, timely, and usable. You could share their responses with your practitioners, and that might encourage the clinicians to craft excellent and useful discharge summaries.

A final tool in your armamentarium could be targeted feedback. Design an audit tool for discharge summaries and task those individuals who read the summaries to use the tool to assess the quality of the documents. There should be a section on the audit tool for comments and suggestions. Compile statistics and share the information and examples with the summaries’ authors.

Remind the providers that someone is reading these documents, they care what the discharge summary says, and it makes a difference in the patient’s longitudinal care.