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Flow of information at discharge

Hospitalist Leadership Connection, September 7, 2010

 Communication at the time of a patient’s discharge can be accomplished several ways. The attending physician can call other healthcare providers over the phone to outline  essential information, such as medications, outstanding studies, and a follow-up plan. A phone call is most likely the most efficient means of communication. However, other means, such as voicemail, are appropriate, especially if the discharge occurs after hours or on a weekend. Many hospitalist programs use a preprinted discharge form that can be faxed or communicated via e-mail. The information in this document should include the following (at a minimum):

• Discharge diagnoses
• A list of discharge medications
• Patient’s disposition
• Plans for communicating the results of any outstanding studies
• Required follow-up studies/appointments with timeline

Regardless of the mode of communication the attending physician uses, the discharge summary should be transmitted to the appropriate care provider as a priority on the day of the patient’s discharge. Information should be dictated in the following order:

1. Patient’s name
2. Medical record number
3. Admission date
4. Discharge date
5. PCP’s name
6. Admission diagnosis
7. Discharge diagnosis (final principal diagnosis)
8. Secondary discharge diagnosis
9. Consultations
10. Procedures
11. Brief summary of admission history and physician examination
12. Pertinent lab, x-ray, and special studies
13. Summary of hospital course
14. Complications
15. Condition at discharge
16. Disposition
17. Discharge plan and physician follow-up: (diet, activity level, ancillary services, medication list at the time of admission, medication list at the time of discharge, required follow-up studies and appointments, including a timeline)
18. Pending test results
19. DNR status

The above excerpt is adapted from Tools and Strategies for an Effective Hospitalist Program, published by HCPro, Inc.
 

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