Discharge summaries in the NHS

This post is all about discharge summaries.
These are also called:
TTO - to take out 
TTA- to take away 
EDN- Electronic discharge summary 
IDS- Immediate discharge summary 

And you will get sick and tired of hearing this term day in and day out when you are working on a ward!

However these are very important as:
1. The patients GP is notified about the patients admission and what happened
2. Any investigations the GP needs to do, any medications they need to review 
3. The patient gets a copy so that they ( and their carers) know what happened in hospital and if there are any changes to their medication 
4. If the patient has any outpatient follow ups. 
5. If the patient goes to another trust which does not have access to the system of your trust, the discharge summary ( which is printed out and given to the patient) is what will relay all the information. 

Every trust has their own IT system and after working in 5 trusts, I really struggle when I start in a new trust ( even with a reasonable experience of working in the NHS for 6 years) as the process of making a discharge summary varies. 
Hence I am going to focus more on the content of the discharge summary.

I will go through each section:

DIAGNOSIS 
Ensure you mention all the diagnoses here. 
All discharge summaries are 'coded' and trusts are paid accordingly. Have a read of this link which explains this:
https://www.hsj.co.uk/technology-and-innovation/an-introduction-to-clinical-coding/5052917.article
Infective exacerbation of COPD 
Hypokalemia 
Constipation

CO-MORBIDITIES 
Mention the patients background - you will view the clerking to enlist these.
COPD, ischemic heart disease, chronic kidney disease, active smoker 

CLINICAL NARRATIVE 
You should explain what brought the patient to hospital 
Mr **** was admitted on the *** with shortness of breath. He had an audible wheeze upon admission. He was not requiring any oxygen. His chest X ray was clear and his bloods showed raised white cells and CRP. Hence he was treated for an infective exacerbation of his underlying COPD with nebulizers, steroids and antibiotics. 
Given his frailty and comorbidities, we discussed resuscitation with Mr *** and his next of kin and it was agreed that he is not for CPR or intubation however he will be for NIV if he deteriorates. A DNACPR form was put in his notes. 
Noted to have an ejection systolic murmur hence an ECHO has been requested as an outpatient. 
He was seen by the respiratory nurses who will follow him up in the community. 
It was noted that he developed hypokalemia- most likely secondary to salbutamol nebulizers, which required oral supplementation. He also developed constipation and was prescribed laxatives. 
His bloods were normal upon discharge. 
He was seen by physiotherapists and was deemed fit for discharge.

MEDICATIONS 
Mention all the medications he is being discharged on 
Mention any changes in his medications

GP FOLLOW UP 
Any advice for GPs
Like - ramipril witheld as inpatient as blood pressure noted to be low. Restarted at low dose upon discharge. Kindly review in 4 weeks and uptitrate to pre-admission dose as deemed fit. 

HOSPITAL FOLLOW UP 
Any follow up requests - like
ECHO as O/P requested as had ejection systolic murmur (no previous ECHOs)

WHY ARE WE PUSHED TO DO DISCHARGE SUMMARIES 
Discharge summaries have prescriptions in the medication list. Once you complete the discharge summary, it goes to the hospital pharmacy and then medications are issued for the patients. This process can take up to 4 hours. And at times, the patients can not be transferred to a place like discharge lounge ( a room with chairs where patients wait for transport) especially if they have infection like COVID, MRSA, are bed bound, etc. 
Hence patients stay lodged on the ward. As a result new patients from wards like AMU cannot be transferred. When AMU fills up, patients are lodged in ED. When patients are lodged in ED, they stay in the ED corridor on trolleys or in ambulances - which are then unavailable to provide essential services. Hence, in order to maintain this flow ( called patient flow), it helps if we do discharge summaries ASAP. 
Most hospitals now have discharge coordinators who try to speed this process up. 

SOME TIPS:
1. Always address the patient by their name instead of 'patient'
Just imagine you being admitted and being addressed as:
'Patient presented with shortness of breath. Patient had wheeze' - Instead, Mr*** was admitted with..... is better 
2. Give a detailed narrative but you do not have to mention figures. Just facts. It should be detailed enough for the patients GP to get the gist of this admission and events as an inpatient 
3. You will get used to doing this in a few minutes. It took me at least an hour  ( or even more) when I did my first discharge summary. It took me 2 hours as ST4 trainee registrar on my first day in the trust - So yes, we all struggle. And I wish we had a better system ( like IT team being physically present and helping us- although this is unlikely in this pandemic). Or maybe all trusts having one system. 
4. Start writing the discharge summary as soon as the patient is deemed fit for discharge or has a clear plan like 
- If bloods today normal, can go home. The bloods will be back in 2 hours. In 2 hours, you might get busy. If you are free now, prepare the discharge summary. DO NOT sign it off till the bloods are back though. What you do not want is someone else printing the discharge summary because it has been completed and the patient going home and then having to come back because the bloods are deranged. 
- If physio happy, home 
In this case, prepare the discharge summary. Complete it and sign it off - as the physiotherapists input will not change the medical plan. It may change the discharge plan and the patient may stay in for longer like waiting for rehabilitation/care home , etc but doing the discharge summary now would help you later in case you get busy. 
5. If you are a registrar, you can still do your own discharge summaries. It makes my blood boil when registrars see a patient in detail, then give the notes to a poor FY1/SHO/ACP who then has to go through the notes in detail and do the discharge summary. It takes literally less than 5 minutes to do the discharge summary - and registrars have been working in the system for a good 3 to 5 years are very good at this. 
6. Unwell patients take priority. Remember no matter how much you are harassed by the nurse in charge/patient flow coordinator, etc if you are the only doctor on the ward and there is a sick patient, you see the sick patient first - hence prioritize that! 
7. Do discharge summaries whenever you are free. The ward round will finish, urgent jobs will be done. Once everything is settled, ask which patients are medically fit/approaching medically fit and prepare their discharge summaries. This will save a lot of time when it gets busy/ when there is understaffing. By preparing, I mean: doing the clinical narrative section, adding the medications to the discharge medication list, etc but NOT signing them off as explained above. 
8. You do NOT need to stay beyond your contracted time to do discharge summaries for patients who are NOT going home the same day- that job can wait till the next day. 

Some other points which will help our GP colleagues:
1. Please be appropriate with your "GP to ***" requests.
What should not happen is things like "GP to chase ***investigation/test/etc". If you have requested it in the hospital, it's your team's responsibility to chase up the result. Most hospitals have ambulatory care units where the patient can come for repeat bloods especially if they need repeating in less than 2 weeks.

2. If physiotherapy/occupational therapy has been involved, it's helpful if we have an idea of what's changed.
Geriatric medicine usually does this very well eg:- Baseline: Fully independent and mobile.
At discharge: 2x/day care, mobilising with 1 walking stick.

3. Please summarise the plan at the end of the letter rather than hiding any actions required within the body of the text,
eg:- Plan:-
1. Outpatient Clinic in 2 months.
2. PT/OT will follow-up patient in community (arranged).
3. Please re-check bloods/BP in 4 weeks and up-titrate Ramipril as appropriate. Make it clear what has already been done, and what you are asking the GP to do.
4. If you have withheld any medications, please explain why and any further action required.

Remember, the discharge letter is often the only communication GPs get from the hospital about a patient's entire stay. It's important that the information is accurate and has all the important details, including important discussions such as those surrounding DNACPR/Anticipatory Care Plans.