From the Guidelines
The procedure for documenting hospital follow-up should include clearly identifying the patient, documenting vital signs at discharge, listing all medications prescribed, detailing procedures and their outcomes, providing specific follow-up instructions, and including warning signs that require immediate medical attention, as outlined in the most recent guidelines 1. When creating a hospital follow-up document, it is essential to start by clearly identifying the patient with their full name, date of birth, medical record number, and admission dates.
Key Components
- Include the primary diagnosis and any secondary conditions that were treated during hospitalization.
- Document vital signs at discharge, including blood pressure, heart rate, temperature, and oxygen saturation.
- List all medications prescribed at discharge with specific names, dosages, frequencies, and durations.
- Detail any procedures performed during hospitalization and their outcomes.
Follow-up Instructions
- Provide specific follow-up instructions including appointment dates, times, and which specialists the patient needs to see.
- Include warning signs that require immediate medical attention, such as fever above 101°F, increased pain, or shortness of breath.
- Document any activity restrictions, dietary modifications, or wound care instructions.
Coordination of Care
- Ensure clear communication with other providers and coordination of follow-up care, as emphasized in 1.
- Conclude with contact information for questions and emergency situations, facilitating continuity of care and preventing medication errors, as supported by 1 and 1.
From the Research
Documenting Hospital Follow-up
The procedure for documenting hospital follow-up involves several key steps and considerations, as highlighted in various studies 2, 3, 4, 5, 6.
- Importance of Follow-up: Follow-up is a vital part of ongoing patient safety, allowing for subsequent investigations to be checked and acted upon, and ensuring that patients with chronic conditions receive appropriate secondary care input 2.
- Components of Discharge Summaries: Discharge summaries should include key information such as medication lists, diagnosis lists, and treatment provided, as these are considered "very important" by primary care providers 3.
- Adequacy of Discharge Summaries: Studies have shown that discharge summaries are often inadequate in documenting tests with pending results and outpatient follow-up providers, highlighting the need for improvement in this area 4.
- Hospital-Course Summarization: The task of hospital-course summarization involves generating a paragraph that tells the story of a patient's admission, given the documentation authored throughout their hospitalization 5.
- Optimizing Discharge Summaries: Primary care clinicians prioritize content such as hospital course, discharge diagnoses, medication reconciliation, and follow-up sections in discharge summaries, and suggest that high-yield content should be presented briefly and succinctly at the beginning of the summary 6.
Challenges and Opportunities
- Barriers to High-Quality Transition of Care: Limited time for primary care clinicians to review discharge summaries and lack of adequate communication between hospitalists and outpatient clinicians are identified as barriers to high-quality transition of care 6.
- Need for Online Systems: There is a need for online systems for requesting follow-up appointments, particularly in hospitals with 24-hour environments and patients being discharged out of normal working hours 2.
- Electronic Medical Record Utilization: Electronic medical record utilization and specific training for clinicians preparing summaries may help optimize the critical information transfer tool of discharge summaries 3.