Discharge Instructions

This chapter was reproduced from the Emergency Medicine Clerkship Primer, 2008, Chapter 14, with the permission of the Editor, for ease of viewing on mobile devices.

Three quarters or more of the patients cared for in a busy emergency department will be discharged home, some after a brief evaluation, others after a more extensive evaluation and hours of observation. For the many patients discharged, outpatient follow-up and reevaluation are required to provide “closure” for the presenting complaint. The importance of providing adequate discharge instructions to communicate with both patients and primary care physicians cannot be overstated.

The importance of providing adequate discharge instructions to communicate with both patients and primary care physicians cannot be overstated.

Discharge instructions serve a number of important purposes. They inform the patient of the known, suspected, or preliminary diagnosis and the name of their treating physician. In addition, properly written discharge instructions can inform the patient and his or her primary care physician about the extent of the evaluation performed, including preliminary diagnostic test results and medications administered in the emergency department. This may also be of help when a patient returns unexpectedly to the same or another emergency department. Discharge instructions can also outline a plan for outpatient follow-up care with the patient’s primary care physician and can explain circumstances under which a patient should return to the emergency department.

Near the top of most standardized discharge instructions is a space to enter the patient’s diagnosis; the diagnosis may need to be entered in writing or through an electronic discharge instruction system. Care must be taken in choosing the proper wording for a discharge diagnosis. A patient’s definitive diagnosis is sometimes not known at the time of discharge from the emergency department. A definitive diagnosis, such as “strep throat,” should be listed only when this diagnosis is in fact known (i.e., in a patient with sore throat and a positive rapid strep test). For many clinicians, there is a temptation to list diagnoses that are suspected but not confirmed. A patient with vomiting and diarrhea may have viral gastroenteritis; however, the vomiting and diarrhea may also represent an atypical presentation of early appendicitis. When discharging such a patient, the safe practice is to list “vomiting and diarrhea” as the diagnosis. After a listing of the diagnosis in the discharge instructions, it is helpful to briefly summarize the evaluation and treatment that was performed, diagnostic test results, and medications administered.

The next part of the discharge instructions should delineate a treatment plan for the patient. Although the treatment plan is often verbally reviewed with the patient before discharge, patients will frequently forget elements of the plan if they are not written down. For example, the treatment plan for a patient with an ankle sprain might include the following: “Apply ice to ankle for 20 minutes at a time, 4 to 5 times per day. Elevate your leg to minimize swelling. Use crutches as needed for comfort.” Medications are often part of the treatment plan and should be clearly explained. For example, “Take ibuprofen 600 mg (1 tablet) for pain every 8 hours with a full meal.”

Another component of written discharge instructions is a clearly stated plan for follow-up care. Specify with whom the patient should follow up and in how many days follow-up should occur. If needed, provide the appropriate specialty clinic phone number for the patient. Remember, based on the type of health insurance, some patients may need to obtain a referral from their primary care physician before they will be able to follow up with a specialist.

The final component of the discharge instructions is perhaps the most important. This includes an explanation of reasons to return to the emergency department. This section should list any relevant symptoms the patient should watch for and should include a generic statement that encourages the patient to seek medical care immediately for any concerning symptoms. For example, a patient with minor head trauma might be discharged with the following instructions: “Return immediately if you develop vomiting, worse headache, weakness or numbness, visual changes, difficulty speaking or walking, confusion, or for any other concerns.”

Several factors contribute to well-written discharge instructions. All discharge instructions should be written in language that can be easily understood by a layperson. It is important to avoid the use of medical jargon. Research suggests that, in general, when providing written health care information, the contents should be written at the sixth-grade reading level. The majority of patients seen in the emergency department do not have medical training and will not understand “CXR neg,” “f/u w/PCP in 2d,” “Keflex 500 mg PO QID,” or many of the other abbreviations we routinely use. Anticipatory guidance about the proper use of newly prescribed medications, particularly analgesics, is important to limit the likelihood of side effects.

It is also of importance to realize that an estimated 50% of the adult US population—approximately 90 million people—have low health literacy and may have difficulty understanding health-related information provided by a physician, including written discharge instructions (Ruddell, 2006). It has been further estimated that 1 in 5 adults cannot read the front page of a newspaper (Ruddell, 2006). In addition, a strong inverse relationship exists between increasing age of the population and low health literacy. According to the 2000 US population census, more than 11% of the population (30 million people) was born outside of the United States (Ruddell, 2006). Approximately 21 million of these immigrants exhibit limited English proficiency (LEP; limited ability to speak, understand, read or write English) (Ruddell, 2006). Patients exhibiting LEP present a number of obstacles to the health care provider regarding diagnosis and management. Language barriers can lead to a lack of adherence to specified treatment plans and have been associated with more emergency department patient visits. Just as interpreter services are used to communicate with a patient during his or her evaluation, interpreter services should be used to review instructions before discharge. If available, have the discharge instructions translated into the patient’s primary language.

Care must be taken in choosing the proper wording for a discharge diagnosis. A patient’s definitive diagnosis is sometimes not known at the time of discharge from the emergency department. A definitive diagnosis, such as “strep throat,” should be listed only when this diagnosis is in fact known

Another important component of well-written discharge instructions is that they clearly explain any outstanding test results that need follow-up. For example, depending on the practice pattern of your particular hospital, a final radiology interpretation by an attending radiologist may not be available at the time of the patient’s discharge. An appropriate way to communicate this to the patient may be, “Preliminary review of the CT scan of your head did not show any acute abnormality. Please follow up with your primary care physician to obtain the official interpretation of this study.” Likewise, although a rapid strep test may be negative in the emergency department, a formal throat culture, if taken, may still be pending at the time the patient is discharged, and the patient must be instructed on how to follow up on this result.

In summary, discharge instructions play several critical roles. They help a patient understand what is known about their condition and what was done for them in the emergency department. They also provide a plan for treatment and follow-up and reasons to return to the emergency department. Taking the time to generate well-thought-out discharge instructions is a habit that should be formed early.

Suggested Reading

  • Ruddell J. Effective Patient-Physician Communication: Strengthening Relationships, Improving Patient Safety, Limiting Medical Liability. Lebanon, Pa: Westcott Professional Publications, 2006.
    • This is an educational module on effective patient–physician communication.