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So it’s your first day on the service. Mrs. Jones has been there for 21 days and has a long list of consultants to address her numerous complications. You see her twice before it’s time to pull it all together and package her up for an 11 a.m. transfer to rehab the next morning. But how do you effectively weed through weeks of documentation to come up with the salient points of the hospital stay, and do so in a reasonable amount of time considering you have 20 other patients (and a few inquisitive family members) who require your undivided attention that day as well?
A preliminary discharge summary, prepared the day before anticipated discharge, can make life a lot easier. If your EMR allows you to sort notes by author or service, you can dictate the hospital course by problem more seamlessly than by reviewing the hospitalization on a day-by-day basis, especially if there are multiple notes from PT/OT, pharmacy, and other ancillary services intermingled in the providers’ documentation.
If your EMR allows you to auto-populate diagnostic test results, discharge medications, and instructions directly into a note, you can create this note on the day of actual discharge, and then copy and paste the dictation of the hospital course into the body of the final discharge summary.
Alternatively, if the provider who is better acquainted with the patient does a discharge summary prior to going off service, the upcoming provider need only add an addendum to this summary on the day of discharge. When partners do these summaries for each other, it can be a tremendous time saver. Instead of spending 45-60 minutes drudging through every progress note and consultation on an unfamiliar patient, you are able to review the preliminary discharge summary and pick up the hospital course as you would for a patient admitted the day before who already has an H&P. The doctor going off service may only need to spend 5-10 minutes dictating the summary.
Of course, different groups have different practice styles. Some groups may consistently dictate summaries prior to going off service, while others may not choose this option. There may be other ways to streamline complicated discharge summaries within groups as well, but experimenting with new and innovative ways to improve care and make our lives more efficient in the process may prove to be a win-win for all.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
So it’s your first day on the service. Mrs. Jones has been there for 21 days and has a long list of consultants to address her numerous complications. You see her twice before it’s time to pull it all together and package her up for an 11 a.m. transfer to rehab the next morning. But how do you effectively weed through weeks of documentation to come up with the salient points of the hospital stay, and do so in a reasonable amount of time considering you have 20 other patients (and a few inquisitive family members) who require your undivided attention that day as well?
A preliminary discharge summary, prepared the day before anticipated discharge, can make life a lot easier. If your EMR allows you to sort notes by author or service, you can dictate the hospital course by problem more seamlessly than by reviewing the hospitalization on a day-by-day basis, especially if there are multiple notes from PT/OT, pharmacy, and other ancillary services intermingled in the providers’ documentation.
If your EMR allows you to auto-populate diagnostic test results, discharge medications, and instructions directly into a note, you can create this note on the day of actual discharge, and then copy and paste the dictation of the hospital course into the body of the final discharge summary.
Alternatively, if the provider who is better acquainted with the patient does a discharge summary prior to going off service, the upcoming provider need only add an addendum to this summary on the day of discharge. When partners do these summaries for each other, it can be a tremendous time saver. Instead of spending 45-60 minutes drudging through every progress note and consultation on an unfamiliar patient, you are able to review the preliminary discharge summary and pick up the hospital course as you would for a patient admitted the day before who already has an H&P. The doctor going off service may only need to spend 5-10 minutes dictating the summary.
Of course, different groups have different practice styles. Some groups may consistently dictate summaries prior to going off service, while others may not choose this option. There may be other ways to streamline complicated discharge summaries within groups as well, but experimenting with new and innovative ways to improve care and make our lives more efficient in the process may prove to be a win-win for all.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
So it’s your first day on the service. Mrs. Jones has been there for 21 days and has a long list of consultants to address her numerous complications. You see her twice before it’s time to pull it all together and package her up for an 11 a.m. transfer to rehab the next morning. But how do you effectively weed through weeks of documentation to come up with the salient points of the hospital stay, and do so in a reasonable amount of time considering you have 20 other patients (and a few inquisitive family members) who require your undivided attention that day as well?
A preliminary discharge summary, prepared the day before anticipated discharge, can make life a lot easier. If your EMR allows you to sort notes by author or service, you can dictate the hospital course by problem more seamlessly than by reviewing the hospitalization on a day-by-day basis, especially if there are multiple notes from PT/OT, pharmacy, and other ancillary services intermingled in the providers’ documentation.
If your EMR allows you to auto-populate diagnostic test results, discharge medications, and instructions directly into a note, you can create this note on the day of actual discharge, and then copy and paste the dictation of the hospital course into the body of the final discharge summary.
Alternatively, if the provider who is better acquainted with the patient does a discharge summary prior to going off service, the upcoming provider need only add an addendum to this summary on the day of discharge. When partners do these summaries for each other, it can be a tremendous time saver. Instead of spending 45-60 minutes drudging through every progress note and consultation on an unfamiliar patient, you are able to review the preliminary discharge summary and pick up the hospital course as you would for a patient admitted the day before who already has an H&P. The doctor going off service may only need to spend 5-10 minutes dictating the summary.
Of course, different groups have different practice styles. Some groups may consistently dictate summaries prior to going off service, while others may not choose this option. There may be other ways to streamline complicated discharge summaries within groups as well, but experimenting with new and innovative ways to improve care and make our lives more efficient in the process may prove to be a win-win for all.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
