Gary Oftedahl: Let’s get rid of hospital discharge summaries
December 18, 2009 at 1:48 pm goftedahl 2 comments
In my 26+ years of practicing internal medicine, a constant thorn in my side in hospital work was the odious task (or so it seemed) of completing a discharge summary upon dismissal of a patient from the hospital. The patient was better, the work had been done, the discharge instructions provided to the patient, or so I thought, and yet, I now had to sit down, and go through the chart, summarizing the hospital episode of care, and reiterating many of the facts already present in the existing record.
Of course the intent was to provide a quick snapshot of the care provided, highlight significant events which occurred (although many were eliminated due to faulty memory, or retrospective bias), note laboratory results of importance, and replicate the discharge instructions which had been provided, hopefully, to the patient or a family representative.
If we’re honest, most of us looked at this as another JCAHO requirement, or redundant work. After all, “discharge” had a note of finality–our work was done, it was now up to someone else to carry the load moving forward–and “summary” implied just that–a synopsis of the episode, a sort of Cliff note version of the entire hospital chart.
With those two words–discharge and summary–I often was able to assuage my guilt (after all I was very busy), and put it aside for a later date. When that time came around, usually after a nasty note from medical records about my delinquent records, I’d drag myself down (isn’t it interesting that medical records are ALWAYS “down” in the basement) and finalize the process.
So I say, let’s get rid of “discharge summaries.” There, it’s out. Let the cacophony of protest begin. ”But we need to provide documentation of the care provided.” ”The follow-up provider will need to see the information.” ”JCAHO will be all over our backs.” One can go on and on.
But the term itself is what needs to go, not the intent. Discharge summary as a term hits part of our brain that allows us to rationally delay the activity. Discharge–done, final, complete, disconnect. Summary–synopsis, outline, short version, overview. The terms impact our brain in a place which allows our decision-making process (which I’ve written about before) in a way which enables delaying behavior.
But in this day and age of early exit from the hospital, increased home care, multiple complex interventions, we recognize the need to move from episodic, acute interventions to ongoing relationships. One isn’t being “discharged” in the sense of finality, but transitioning to another level of care, a different location to continue our efforts. It might be long-term care, transitional units, home care or self care–but it’s a transition. And it needs to be seamless, with adequate information provided to support those assuming the care role–a directive if you’d like.
So, I suggest, in the spirit of understanding that words are incredibly important, that we replaced discharge summaries with “transition directives.” Think of the difference in emotional impact. With the switch in language, we’ve assigned a whole new importance to the work. Transitions are messy and require coordination, directive suggests providing critical information to moving forward. It’s not about a “summary” looking back, but looking forward to the patient’s needs which will still be critical to address. As a human impacted by a strange compendium of prefrontal and limbic connections, I (only speaking for my cerebral function) would be drawn to completing and providing such an important document. What, you say, it’s nothing more than relabeling what we already do? Perhaps, but it would allow for a reframing and reconfiguring of our processes.
Perhaps some are already contemplating this, but I’ve often thought that it’s an embarrassment that after more than 30 years in medicine, I’ve seen little movement toward improving the hospital discharge process (Oops, there, I’ve done the same thing). While whimsical in print, moving from “discharge summaries” as a part of the routine, to the use of “transition directives” could be a small part of changing our perceptions of the work, enhancing the value of the effort, and engaging us in understanding the importance of this critical piece of the hospitalization effort.
So, what next–say, how about getting rid of the term “past medical history.” That’s always kind of seemed strange to me also….but that’s for another day.
Entry filed under: General Info, Health Care Redesign. Tags: .
1.
Randall Reitz | December 19, 2009 at 9:32 am
When I read your title, I immediately started to sharpen my pitchfork for a torchlight rally. Alas, you weren’t fomenting quite the rebellion that I initially anticipated.
Your term “transitional directive” is more accurate in the contemporary hospital environment. My only concern is that it evokes military speak and for many, a “transition” that occurs in a hospital is inexorably connected with death and “transitioning to the other side”. That being said, were I a patient in a hospital, I would much rather be transitioned than discharged.
2.
Harold D. Miller | December 19, 2009 at 12:00 pm
Excellent post, Gary. The only thing I would disagree with is the term “directive.” It implies that the hospital is directing the patient’s care post-discharge, and in many cases (maybe most?), the patient’s overall care should be managed through a community-based medical home. Ideally, the discharge orders and patient instructions should be coordinated with the patient’s primary care practice and family BEFORE discharge to ensure they can be appropriately carried out. Perhaps the discharge communication should be called “transition information and recommendations?”