The Gold Standard for Clinicians--The Discharge Instructions Robert M. Blumm, PA, PA-C, DFAAPA Clinical Consultant for CM&F

Do we, as clinicians, underestimate the importance of communication, particularly discharge instructions? Communication starts when a patient enters our system, whether in a hospital, nursing home, urgent care clinic, or private practice. This is reflected in a more exacting and permanent manner by an EMR (Electronic Medical Record). This record affords all who are treating the patient with clarity as to the chief complaint, PMH, PSH, psychiatric and sexual histories, family presence, language, age, concerns, ability to have insurance to be treated, ability to purchase prescriptions and to understand their HCP and have the means to travel to an appointment, with a caregiver if necessary to help in the understanding of the patient’s condition and to interpret if needed. If these charting aspects are available, we will better understand our patients and know medications that may be contraindicated. Every person who signs on to this chart has this information, and it is there because someone is expected to look at the comments. This protects a patient through every step of their medical journey: their treatment, surgery, follow-up care, and, most importantly, their discharge instructions. These instructions must be understood and followed so that this patient does not become a statistic of 19% of patients who return to the facility with an adverse event within two weeks of discharge. I have seen patients die because of this, and I am sure that, with reflection, you may recall a preventable tragedy. A contributing reason for the untimely death of my father-in-law ten years ago was the fact that no one charted his steroid use for RA.

Professionals involved in Quality Care as their responsibility have projected their focus or attention to the Achilles’ heel of patient care and institutional and personal responsibility and liability. It is indisputably the transitional part of care and is the most dangerous: how should the patient be treated upon discharge? Why is this of the utmost importance? Performed in a standardized manner and given the attention it deserves, the very prognosis of the patient is at stake. Appropriate attention is essential, as it will determine the trajectory of the patient’s well-being, improvement, recovery, and, perhaps, survival. Therefore, my colleagues, we need to give this communication skill our attention as it becomes our best weapon in this warfare against disease and the ability to heal.

Please do not take umbrage with this assertion. As a clinician of forty-seven years, I am aware that sometimes the incessant noise and distractions of our work areas can cause us to lose focus or become too assuming and then forget the pearls of excellent patient care.

What do I desire for my patient to understand? How do I meet their expectations? Our responsibility is to explain all their discharge planning in their language and sufficiently for their capability to understand. What does this consist of? Medications and when they are to be taken, even though it will be placed on the label by the pharmacist. Diet is essential. Do they need any ROM, wound care, or physical therapy from a licensed provider? Could you communicate follow-up appointments with names, times, and telephone numbers for confirmation? What must they or their caregivers be aware of regarding reactions, warning signs of problems including infection, dehiscence or SOB, and LOC? If these were to occur, who is the physician or service they can call with a response, i.e., NOT a recording? Of particular importance to me is the fact that there may be a language problem, and the proper interpreter needs to be called in. They may understand the language, but what is their cognitive ability to understand the meaning of your instruction? It needs to be in lay terms and as simple as is required in each situation. Who is the caregiver if one is needed?

Many large health institutions rely heavily on prefabricated discharge instructions: enter your discharge diagnosis, and a set of attorney-approved preemptive options magically appears! But please know and adapt the content for your patient. It alienates and can confuse the patient when the information included does not apply to them. One of our obligations as health care providers is to push back against the institutional model that reduces our task to simply accessing our computer-borne options. Patients expect and have a right to individualized care that meets their needs appropriately.

“To the world, you may only be one person, but to one person, you may be the world.” (anon) When we treat our one patient, it is not in a vacuum as the family members are observing, as are their friends, the nursing staff, the administration, quality assurance, and a prosecuting attorney with their highly competent paralegal and other research staff. Does our treatment meet the SOC of the institution or the practice? Is my care for my patients my personal best? “Don’t let what you cannot do interfere with what you can do.” (John Wooden ) You may not be able to change the outcome of a stage 4 metastasis, but you can be there to hold a hand and offer a smile and hope or affirmation. We are repeatedly encouraged to observe the essential aspects of medical and nursing practice, which has always been, to me, putting the patient first. Performing a proper discharge will ensure the best of our care, and offering only an abbreviated note without all the information I just commented on is to flirt with a patient’s successful care and well-deserved litigation. If that were to happen, are you secure with your insurance? Has it covered everything you expected? Is your name on the policy? Is it current, and is it paid for? Is it a Term or Occurrence? Can you afford not to purchase a policy that reflects your experience and ability, a Best ++ rated Superior policy, and enjoy the peace of mind it gives? I did!

Written For CM&F By Robert M. Blumm, PA, DFAAPA, PA-C Emeritus