Features and Contents of a Discharge Summary Letter
A discharge letter presents relevant information regarding the health status, diagnosis and feelings of the patient. In the event such a letter was not available, a general practitioner could not be in a position to understand the health status of the patient, her or his healthcare needs and hence make appropriate medical treatments.
Rola, and Varela (2000) explains that there are aspects associated with the quality and proportion of discharge letters which in many cases affect the management of shared health after discharge of the patient from the hospital. In order to provide an effective management of a given condition, it is important that a physician has relevant information of the patient so as to understand current status and diagnosis, prior care and hence: create an effective treatment plan. In order for the provider to ensure that all relevant information is captured, the discharge information has to be complete, readable, concise, and be as timely as possible.
Foster, Paterson, and Fairfield, (2002) explain that discharge summaries must have enough and relevant content with legible information. Moreover, the document has to contain complete patient information, diagnosis and treatment and follow up. Additionally, medication information has to be accurate and timely (A Clinician’s Guide to record Standard, 2008). Nonetheless, key issues in relation to documentation of immediate discharge relate to the timeliness and quality of the documentation (National Prescribing Centre, 2008). Concerning the structure, majority of GPs have a preference to structured format in relation to the narrative style. A structured format allows the information to be processed electronically. Electronic transfer of discharge summaries has been considered as a way to address the content, legibility and timeliness of the information (Green, 2006
The immediate discharge summary captures various types of data whose aim is to make the GP informed of the key issues pertaining to the patient’s hospital stay (Bolton, 2001).
Other details include:
. Patient’s stay in the hospital
Diagnosis and treatment provided
Medication changes in the course of hospital stay and monitoring
.Admission and discharge dates
.Reconciled and comprehensive medical list
.Information on drugs started and stopped and the reason thereof.
.Problems at discharge