Accurate Discharge Summaries Vital for a Patient’s Ongoing Healthcare

Accurate Discharge Summaries Vital for a Patient’s Ongoing Healthcare

Accurate discharge summaries are crucial to ensure proper ongoing care for patients discharged from hospitals.

A medical transcription company can ensure maximum accuracy.

Technological advancements in the healthcare industry have led to major medical innovations and significant changes in the way how medical records including History & Physical report, Consultation report, Operative note and Discharge summary are maintained. Medical records are a combination of both self- reported patient information and a physician’s notes on diagnosis, care and treatment given to the patient. Typically when a patient visits a physician, he/she diagnoses the patient and dictates the patient’s medical condition via a digital recording machine. Doctors have always found the dictation-medical transcription process convenient, and a more accurate form of recording important healthcare details. Medical transcription companies have therefore remained as an important part of the healthcare industry ensuring that the medical records are available in a timely manner and are accurate. Now, even in this EHR age, many physicians and healthcare providers depend on professional EHR-integrated transcription services to maintain reliable medical records.

Discharge Summary – One of the “Big Four” The discharge summary is one of the “Big Four” medical records, the others being History & Physical report, which explains the nature and complexity of a patient’s condition; Consultation report, which includes the physician’s evaluation of the patient; and Operative report, which contains pre- and post-operative diagnosis, procedure names and a long narrative encompassing every other detail. The Discharge summary is a clinical report prepared by a physician or a healthcare professional about a patient’s health condition from admission till discharge. It outlines the patient’s chief complaint, the diagnostic findings, the therapy administered and the patient’s response to the medication, and treatment and recommendations on discharge.

Discharge Summary and Its Legal Implication The discharge summary is an important legal document like other medical records in case of an adverse event. Take the case of a consultant psychiatrist at a mental health unit in Barrow, UK who was subjected to a fitness to practise probe by the General Medical Council (GMC) in connection with the death of a 42-year-old male patient. This patient was found dead at his home in Barrow after a fatal codeine overdose. He had been sectioned under the Mental Health Act, but was released from the mental health unit by the above mentioned doctor who later admitted that the decision to discharge the patient was based on a “10-15 minute conversation with colleagues’” while he had spent only 30 minutes speaking to the patient himself. An expert commissioned by the GMC found that the doctor did not properly assess the patient’s mental health problem and risks involved. He relied excessively on the views of junior staff and did not

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completely determine the background history of the patient available from care records, the patient’s general practitioner and his family and friends. Importantly, the medical discharge summary that was completed after the patient’s death displayed significant inaccuracies such as the patient had made no previous suicide attempts or self-harm whereas he had indeed attempted suicide twice and had become ill after a relationship breakdown. The discharge summary therefore gives the impression that the doctor was not aware of the crucial details of the case.

This case throws light on the importance of accuracy when recording details regarding patients in the medical records. This is one area where treating doctors have to be especially cautious not only in observing the patient and making the diagnosis but also in ensuring that all relevant details are accurately documented. It is true that professional transcriptionists can identify gaps in the narrative or missing information and would request clarification from the provider. However, the onus is on the physician to make sure that all facts are included.

A discharge summary becomes a death summary when a patient dies before he is discharged from the hospital. A death summary is a standard medical report that includes the time and date of death. It also includes whether the patient’s family had agreed to an autopsy or whether the patient had a living will that called for “no aggressive therapy,” or “do not resuscitate.” In the absence of a living will the family can make a decision and the death summary would include this information as well.

A death summary is similar to a discharge summary but differs in the following ways: 

Discharge date is changed to date of death

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Discharge diagnoses is changed to final diagnoses

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Cause of death may be dictated based on whether the actual cause was known/unknown at the time of dictating the death summary. Sometimes a pending surgical pathology report or an autopsy report may be required to understand the cause of death

Treat the Patient’s Discharge as the Next Step in His/Her Care Creating the discharge summary is an important part of performing the discharge service (i.e. performing the final examination of the patient, discussion of the hospital stay, instructions for ongoing care, preparation of discharge records, prescriptions and referrals).

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

The discharge summary informs future care providers regarding the patient’s hospital stay and the post-discharge plans.

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Typically a four to eight page document, the discharge summary is very important

for hospitals to help

document

the medical

necessity of the

hospitalization for hospital billing purposes.

A discharge summary just as other medical records must be very accurate, and an experienced medical transcription service company can ensure this. To speed up hospital processes such as discharge, they also provide real-time transcription services. The best mindset when preparing a discharge summary is to consider a patient’s release from the hospital/healthcare facility as the next important step in his/her care rather than as the final step, as Sharon Hewner, assistant professor in the Buffalo School of Nursing, who is leading a study on automating hospital discharge communication and reducing readmissions, points out.

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1-800-670-2809