How to write a good discharge summary (7 top tips)
Key points
Think about why you are doing it, and who is the reader
Describe the salient points of the admission, and in a logical structured way
Paragraphed properly (3-4 sentences per paragraph)
Do not include so much information that people will not read it
Relevant negatives (unless very relevant) and abbreviations are not helpful.
What is a discharge summary and what are they for?
It is the only piece of information the GP receives about your patients’ entire admission (anything from 1 day to many months). They need to have an understanding of key events and decisions that occurred.
First of all, be clear on why you are writing the letter. There are 4 reasons for the summary (all related to the ‘3 C’s: communication, communication and communication’):
Communication with GP (or other health professionals) – to encourage action they need to take
Communication with patient – to encourage action they need to take. Copy directly to the patient whenever possible
Communication with hospital colleagues – in other departments, or if the patient comes in as an emergency
Medicolegal record – i.e. a record of the admission.
Who writes them?
Writing discharge summaries is traditionally the task of junior doctors. They may have had formal or informal training about how to do them. Discharge summaries are often seen as a low priority for pressurised junior staff; who might not have had sufficient feedback and supervision in how to produce high quality summaries. So, you can do better.
Oh yes. GP’s are too busy to read War and Peace, and you are too busy to write it. Finding the balance will come with time and experience, but do NOT copy the entire text for every scan or put every blood test result.
Now, let’s start. A good discharge summary should have 6 components:
Start – consultants name at the top (they take ultimate medicolegal responsibility for the patient’s care).
We have described how to write a good discharge summary (7 top tips). We hope it has helped you. One final point to remember is that perhaps some time in the future, you will be on the receiving end and will appreciate a job well done.