Video walks through the keys to producing a “consistent and meaningful” Discharge Summary to help patients have a smooth transition after they leave the hospital. (Video: UHN)
Every year, more than 35,000 patients are discharged from UHN.
As some individuals are admitted and leave more than once, that generates nearly 50,000 Discharge Summary reports, which are sent to the primary care and referring physicians of each patient.
The Discharge Summary is a clinical report outlining a patient's chief medical conditions. It has such things as significant diagnostic findings over the course of the hospital stay. It also lists recommendations for follow-up care.
Discharge Summaries are integral to family practitioners and other medical specialists who resume the care of UHN's inpatients. The documents are composed by learners of all levels, with guidance from attending staff.
Completing high quality Discharge Summaries is a critical component of the care provided. And, the
UHN Discharge Summary website is designed to help learners understand the importance of Discharge Summary quality and its timely completion and delivery.
"It is very important that learners are aware of what a good Discharge Summary entails and the value provided by one," says Dr. Richard Dunbar-Yaffe, MDCM, Chief Medical Resident, Toronto General Hospital. "Discharge Summaries have to concisely communicate the very complex hospitalization of our patients.
"The summary is a vital method of communication between physicians – one that cannot be substituted with e-mail or phone conversations."
Dr. Dunbar-Yaffe says the UHN Discharge Summary website features many of the positive characteristics looked for in a good document.
"It uses concise and plain language to encourage learners to provide high quality Discharge Summaries," he says. "I would encourage my fellow residents and students to take a few minutes to read through it prior to completing their first Discharge Summary."
To access the UHN Discharge Summary website:
- Visit the UHN Public website (UHN.ca – For Staff – Training)
- Visit the UHN Corporate Intranet website (Departments – Health Records – Chart Completion)
- Click on
www.uhnmodules.ca/DischargeSummary/
- Scan the QR code below
Dr. Richard Dunbar-Yaffe, seen here accessing UHN’s Discharge Summary website on his iPhone, says Discharge Summaries “have to concisely communicate the very complex hospitalization of our patients.” (Photo: SIMS)
Five tips from Dr. Richard Dunbar-Yaffe on what makes a good Discharge Summary
- Brevity is
extremely valuable. Including only pertinent details of the hospitalization increases the probability of the patient's subsequent care providers understanding the course in hospital, and where to
"pick up the baton" regarding the patient's care.
- It is vital that attending staff and learners complete Discharge Summaries utilizing UHN's best practices, and within 48 hours of the patient's discharge.
- Place importance on the patient's follow-up plan. Emphasize items that the patient's specialists should be concerned about and symptoms the patient should be concerned about.
- Pharmacists play an integral role in medication reconciliation – an important component of the Discharge Summary that helps prevent the possibility of adverse events post-discharge.
- Verify the patient's relevant medical history. Errors are committed through a "copy and paste" mentality.