Objectives

2. 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.

3. 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

4. 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

5. 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!

6. 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

7. Hospital Course • 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. For example, in a diabetic patient who presented with a stroke:

8. Hospital Course • 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. For example, in a diabetic patient who presented with a stroke:

9. 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

10. 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

11. 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.