Discharge Summary Guidelines

What is a discharge summary?

The discharge summary is a written communication tool that allows the efficient transfer of information between the primary and secondary healthcare settings. An accurate and complete discharge summary helps patients and providers successfully transition care avoid harm in the vulnerable period after a hospital discharge.

 

What should be in my discharge summary?

At Temple, we have a template in EPIC for writing a discharge summary. You should use this template and fill out any pertinent areas.

Here is a non-exhaustive list of things to include when writing a discharge summary:

Primary Diagnosis Secondary Discharge Diagnosis/Diagnoses
Hospital Course Procedures/tests performed during admission with summarized results
Patient instructions Information regarding social support or living situation of the patient
Functional capacity at discharge Cognitive Capacity at Discharge
Physical exam at discharge Lab results at time of discharge (i.e. hemoglobin, creatinine)
Any test or results still pending or specific comment that nothing is pending Recommendation for follow-up tests/procedures/specialist follow-up (if appointment not made)
Resuscitation status Etiology of heart failure (if applicable)
Reason/trigger for exacerbation (if applicable) Ejection fraction
Discharge weight If stent placed, whether drug-eluting or not

 

How long do I have to write the discharge summary?

Discharge summaries can be started during the hospital stay. It may be wise to start early if the patient has had a long hospitalization. If the patient is awaiting placement and not much is changing clinically, this is a good opportunity to start early.

Discharge summaries are due at the latest 30 days after the patient was discharged. However, discharge summaries are often completed on the day of discharge. This is ideal, as post-hospitalization PCP and specialist appointments are often within days of the discharge.

For purposes of compliance, having any discharge summary > 30 days old, or ≥ 10 discharge summaries will flag a resident as suspension eligible. This list is compiled every Thursday. Suspension eligible residents have until Midnight the following Monday to complete all outstanding discharge summaries, or risk suspension.

 

Who is responsible for discharge summaries?

Creating a discharge summary is a necessary skill in systems based practice and patient centered care. In our program, interns begin writing discharge summaries on September 1st. Due to the volume of patients we see, discharge summaries are split with the majority being completed by the intern on the team, and the remainder being completed by the R2/R3. The split should be 2/3 of discharge summaries authored by the intern, with 1/3 authored by the resident. This should entail a conversation between the intern and resident to decide which patients are assigned to whom.

If a discharge summary is received in error, or needs to be done by another person (i.e. resident sending to intern, or intern sending to resident) this must be sent within 24-48 hours of receipt for a new discharge summary. Discharge summaries that are already overdue may not be sent to a different resident, unless the original recipient did not care for the patient at all. This is to ensure fairness, and the ability to complete the discharge summary in a timely manner.

Upper year residents are encouraged to keep tabs on their interns’ discharge summaries and ensure they are meeting standards of completeness, clarity, and accuracy. This responsibility also falls to the attending physician.