Discharge summaries

The patient’s in-hospital chart,

I’ll finish right now, if I’m smart

The time I can ration

To complete the dictation,

To describe the finish and start.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

Completion of a hospital medical record demands a discharge summary.  Nobody ever showed us what a good discharge summary looked like in med school.  We learned from examples, mostly bad.

Med student discharge summaries didn’t count.  In residency I went for thorough at the expense of brevity.  I regurgitated the history and physical, admitting lab and x-ray results, admitting diagnosis, hospital course, and discharge planning in excruciating and unnecessary detail, going through the layers of paper chart day by day. Sometimes the discharge summary went to three pages, single spaced. 

In the Indian Health Service I had to cut back on my words.  However intelligent and hardworking a transcriptionist might be, lack of training in medical terminology made for a lot of errors to correct to finish the product.  Just as well; when I took to typing out my own discharge summaries I pared down the turgid phraseology and left out a lot of irrelevant numbers.  The documents became more useful.

Medical chart completion ranked low on my priorities for most of the time I spent in private practice.  I found motivation only in the periodic letters I got from Medical Records telling me I’d be suspended from the staff if I didn’t finish my charts.

Through my career the grace period, from the day of discharge to the date of suspension, has shrunk from a year in the 70’s to six months in the 80’s, and has now remained at a well-enforced 90 days for the last 15 years. 

But the pace of medicine keeps accelerating.  We strive to follow the patient less than a week after discharge, and the follow-up doc usually didn’t see the patient in the hospital.  The discharge summary becomes less of a formality and more of a necessary and useful document.  I usually dictate the summary at the time of discharge, standing in the hallway.

My format has changed.  A line or two for the story of why the patient came to the hospital, a paragraph each for relevant past medical/personal/family/social history and abnormal physical findings.  A paragraph for lab and x-ray, followed by a paragraph for hospital course, discharge medications plans, and final diagnosis. 

Even at that, a long, a complicated hospitalization (one recently lasted 29 days)can give rise to a two-page discharge summary, but most take a page or less.

In that short space, the necessary confines for a useful document, I can give the facts but not the meaning.  I don’t get to use phrases like self-defeating behavior or inadequate reality testing or stinkin’ thinkin’ or self-imposed social isolation.  If I dictate patient refused counseling, I don’t get to go into the nitty-gritty of why.

The hardest discharge summaries end with “The patient continued to deteriorate and died on…”  Such a stock phrase gives a hollow echo of the drama and irony playing out the final act on the hospital stage, but such phrases I use on a regular basis.  And every time, I can’t help but pause.  The patient gets a moment of silence from me, whether I intend to or not. 

The transcriptionist, I am sure, hears in my voice how my world diminishes with every patient’s death.