Shift work, duty hour limitations, and the increasing disconnect between hospital-based and clinic-based physicians have conspired to make the time during and immediately after discharge from the hospital fraught with opportunities for medical error. Thus, the ability to discharge a patient according to the best practices outlined in the medical literature is a necessary skill for all medical residents.

• Availability of discharge documentation: Although it seems obvious that a patient discharge from the hospital would work best as a collaborative effort between the discharging hospitalist team and the receiving ambulist team, a true collaboration rarely happens. Only 3% of PCPs report that they are routinely involved in discussions about the discharge of 1 of their patients. Fewer than 20% feel that they are routinely informed in any way about 1 of their patients being admitted to or discharged from the hospital. Twenty-five percent of dictated discharge summaries never reach the intended PCP and, not surprisingly, 66% of patients who arrive for a follow-up visit are seen without a discharge summary available to the PCP. A clear and ordered discharge process would improve these statistics.
• First, discharging physicians must complete discharge documentation immediately on a patient's discharge. Forward-looking hospital systems often require that a discharge summary be dictated, and status transcribed and signed before a patient is allowed to leave the hospital. The second step is to make sure the PCP receives the information as soon as possible. Remember that although the patient may not see the PCP for 1 or 2 weeks, questions directed to the PCP may begin mere minutes after the patient leaves the hospital (ie, from a pharmacy questioning a drug dosage or interaction). PCPs find personal letters (as opposed to a copy of the discharge summary) and phone calls to be the most helpful way to communicate issues at discharge. While this may not be possible for all discharges, it is important to consider making personal contact with the PCP on complex or sensitive patient cases. Phone calls between providers at discharge can be immensely helpful, as it permits a 2-way conversation about the patient. In our opening scenario, it is clear that the absence of a discharge summary when the patient presented for a follow-up began the chain of events that led to a poor patient outcome.
• High-quality documentation: The data related to the quality of the discharge information that does reach the PCP suggest that there are many opportunities for better practice. Written paperwork is illegible at least 10% of the time, the main diagnosis is missing from the documentation 17.5% of the time, reasons for medication changes are clearly explained only 21% of the time, and the name of the main doctor caring for the patient during the hospitalization is missing in 1 quarter of all discharge summaries. Recalling the opening scenario in this chapter, a legible discharge summary explaining why warfarin was being held would have eliminated the need for the PCP to make an educated guess about her patient's pathology (which, in this case, turned out to be wrong).
• Pending laboratory tests: Tests that have been ordered and performed but not resulted by the time of discharge deserve special attention by the discharging physician. A full 3 quarters of patients leaving the hospital have pending lab tests, 15% of which turn out to be abnormal. Most of these abnormal tests are seen by neither the hospitalist team after discharge nor the PCP's team, which is unaware that any testing has been done. The medical and legal liability of letting a patient “fall through the cracks” at discharge in this way is of significant concern. Few hospital systems have a foolproof way of making sure these results are seen by a physician who can take responsibility for acting on the results.

In order to avoid these common errors at discharge, it is important that physicians get into the habit of following a checklist of tasks when discharging a patient.

1. Make sure the patient and/or his or her caregivers understand the important diagnoses or issues that necessitated the admission to the hospital. Use the teach-back method to make sure the patient understands, and supply brochures, handouts, or illustrations to help reinforce the concepts. Make sure to dictate these diagnoses into the discharge document.

2. Summarize the pertinent medical history and the key physical findings in discharge documentation. For instance, for a patient with CHF and pulmonary fibrosis, it would be important to note that even when the patient was clinically no longer in a CHF exacerbation, there were still crackles on the lung examination due to fibrosis.

3. Include the dates of hospital admission and discharge with a brief narrative of the hospitalization. Novice doctors often spend most of their time on this part of their discharge summary, when in reality it is the least read section. Be brief and problem oriented.

4. List the procedures done and key lab results in the discharge summary. Do not create an unreadable “data dump” by including all available information—make a decision about what to include based on the patient's active problems. For instance, that a patient's creatinine remained normal for 10 days only needs to be mentioned once, but the evolving INR and changing warfarin doses for new-onset atrial fibrillation should be mentioned in detail.

5. Include a medication list, broken down into previous medications and current medications. Call attention to medications that have been stopped, had their doses changed, or have been added. List not only the medications but their indications as well. Finally, make sure to “de-autosubstitute” medications. For instance, if your hospital automatically changes your patient's omeprazole to an equivalent dose of esomeprazole, make sure his or her medication list at discharge lists his or her home medication, omeprazole, as his or her PPI. Failure to do so can result in harmful (and expensive) medication class duplication.

6. If your patient was seen by specialists, include a list of them in the discharge summary. Make sure to list the names of the attending physicians and the problem for which they saw the patient. “Patient was seen by Dr. Friend of GI for peptic ulcer disease” is much more informative than “Patient was seen by GI.”

7. If you spent time educating a patient or family on a medical issue, indicate that in the discharge documentation. “Since patient was new to warfarin, we discussed eating a vitamin K–consistent diet and supplied a handout” can help the PCP know education needs remain for the patient.

8. Describe the patient's functional and mental status at discharge, so that the PCP knows if the patient's “baseline” has changed. If changes have been made in the DNR status or advanced directives, make sure to describe them. If the patient is being sent to an extended care facility (ECF) or home with assistance, note that in the summary.

9. List all the follow-up appointments and recommendations in the discharge document so that both the PCP and the patient (who may receive this information by way of written prescription or a printed list at discharge) know future plans. By doing this, you make it easy for the PCP to be on the lookout for follow-up information, and make it easier to help the patient comply with follow-up recommendations.

10. Call special attention to the patient's critical follow-up needs. The last section of the discharge document should be a bulleted list of important follow-up issues. Using the patient from our opening scenario as an example, it is clear that a summary statement in a discharge summary that said “Important Follow-up Issue: Per Dr. Friend of GI, this patient can re-start his warfarin therapy in 6 weeks barring further issues” would have prevented the medical error that was made.

11. Include the name of the attending physician in the hospital and contact information. Patients meet many new people during their hospital stays, and few can name their attending physicians. Providing this information is crucial to facilitating good communication between the hospital team and the patient's outpatient team.

12. Give or send the patient a copy of the discharge summary. This is vitally important for patients who have yet to establish with a PCP or who are from out of town. On a very literal level, the only way to ensure that a patient arrives at an outpatient appointment with all pertinent information is to place the information in the patient's hands.

A 76-year-old man with an eighth-grade education who is chronically anticoagulated on warfarin for a history of paroxysmal atrial fibrillation, is admitted to the hospital with an upper GI bleed. His warfarin is reversed with vitamin K, and upper endoscopy reveals an actively bleeding duodenal ulcer. A CLO test confirms the ulcer was caused by H. pylori, and the patient is then placed on a proton pump inhibitor and appropriate antibiotics. After discussion with the GI consultants, the hospitalists advise the patient as he is being discharged to follow up with his primary care physician (PCP) and that he can restart his warfarin in 6 weeks.

When the patient arrives for his outpatient follow-up visit, his PCP is surprised to hear that her patient was in the hospital. No discharge summary is available, so his doctor relies on the patient to tell her what happened. Unfortunately the patient does not remember all the details. He does remember something about the problem being caused by an “infection in my stomach,” and he also notes that he was taken off his warfarin. Worried that her patient might have a stroke if he remains off his anticoagulant and thinking her patient had a viral gastritis, the PCP restarts his warfarin. One week later, the patient develops melena and is readmitted to the hospital with a recurrent GI bleed.