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Generic discharge summary*

From the June ACP Hospitalist, copyright © 2012 by the American College of Physicians

By James S. Newman, MD, FACP

It's 9 a.m. The social worker is telling you the nursing home needs your patient by 10 a.m…and you haven't yet started the discharge summary.

Not a problem. Use this handy-dandy generic discharge summary to get the job done! What you lose in accuracy, transitions of care, patient safety and satisfaction will be more than compensated with your personal time saved.

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Courtesy of Dr. Newman.

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Discharge summary on your patient

Admit date: Earlier this week.

Discharge date: Today.

Discharge diagnosis

1. Asymptomatic pain—resolved
2. Abnormal laboratory value
3. Incidental radiologic finding
4. Iatrogenic vital sign—aberration
5. Non-diagnostic endoscopy
6. Non-hypoxic hypoxemia
7. Idiopathic hospitalization
8. Nosocomial sleep disturbance syndrome

Hospital course

The patient arrived in the emergency department, where he was registered. There was an evaluation by the nurse and physician in a relatively timely manner. An extensive number of labs and images were obtained, several of which were markedly abnormal, and some of which were within normal limits. After consideration, intravenous therapy was contemplated and steroids were considered. There was a heated debate about whether the patient should go to the ICU, surgery, neurology, pediatrics, OB-GYN, rehab, or just be discharged. Finally the patient was, of course, admitted to our hospital medicine service.

On arrival, the patient was placed in a room. Vital signs were rechecked. The team arrived and obtained the history and performed a physical exam. More labs and images were ordered, and high-cost therapy was initiated. Admission orders were placed. A diet was ordered, though NPO status was an option for procedures that might or might not be done. Physical therapy and occupational therapy consults were contemplated.

The patient had variations of the measured vital signs and adjustments were made to the regimen. Certain medications were held, and restarted at adjusted dosages.

The family gave additional non-pertinent information. Numerous questions were asked and several actually answered. DVT prophylaxis was on our radar.

The patient looked really sick for a while and we thought about transferring him to the ICU, CCU or surgery service but then he appeared to improve. We noted a window of opportunity, and discharge plans were made for transfer to another location.

Condition at discharge

Dischargeable.

Past medical history

Multiple previous surgeries

Undefined disease of the heart

Asymptomatic nodule

Intact mentation

Seronegative noninfectious viremia

Non-diagnostic gland biopsy

Unpronounceable syndrome

Family social history

Contributory and significant family history key to the case was identified. Various social habits that may impact health adversely were noted. The patient may have been retired and had possible tobacco exposure, or not.

Code status

There were extensive discussions about code status. We reviewed the prognosis and outcomes of inpatient cardiac arrest and the options available. After prolonged debate with the patient and family, a decision was made.

Medications

Continue pre-admission medications, except for the ones we discontinued. As well as those we added.

Follow-up recommendations

Patient should follow up with a doctor post-hospitalization. The patient will contact doctor and set this up. Patient should also continue the medication regimen as ordered unless side effects occur, which is very likely, in which case maybe he should stop medications if he thinks it's a good idea.

Patient education

Patient was told that, should there be questions, he should contact someone sooner or later—probably sooner, although we will be out of town.

Patient was also told not to be readmitted within 30 days.

*No vaguely useful, actual patient information was used in preparing this document.

Dr. Newman is a hospitalist at Mayo Clinic in Rochester, Minn., and ACP Hospitalist's editorial advisor and humor columnist.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated