From the Guidelines
A discharge summary should be transmitted to the primary care clinician as soon as possible after discharge, including information on medication changes, pending tests and studies, and follow-up needs, to ensure continuity of care and prevent potential complications or readmissions. This is based on the most recent and highest quality study, which emphasizes the importance of structured discharge communication 1. The discharge summary should include details about the patient's hospital stay, such as admission diagnosis, significant findings, procedures performed, treatments administered, and the patient's condition at discharge.
Key areas to be reviewed and addressed before hospital discharge include:
- Identification of the health care professionals who will provide diabetes care after discharge
- Level of understanding related to the diabetes diagnosis, glucose monitoring, home glucose goals, and when to call a health care professional
- Definition, recognition, treatment, and prevention of hyperglycemia and hypoglycemia
- Information on making healthy food choices at home and referral to an outpatient registered dietitian nutritionist or diabetes care and education specialist to guide individualization of the meal plan, if needed
- When and how to take blood glucose-lowering medications, including insulin administration and noninsulin injectables
- Sick-day management and proper use and disposal of diabetes supplies, as outlined in the most recent guidelines 1.
By prioritizing the transmission of accurate and prompt discharge summaries, healthcare providers can facilitate smooth transitions of care, prevent potential complications or readmissions, and ultimately improve patient outcomes, particularly in terms of morbidity, mortality, and quality of life 1.
From the Research
Discharge Summary Components
- A discharge summary is a crucial clinical document that summarizes a patient's clinical information and relevant events during hospitalization 2
- The key components of a high-quality discharge summary include:
- Discharge diagnosis
- Treatment received
- Investigation results
- Follow-up plan 3
- These components are essential for effective communication between inpatient and outpatient physicians, as well as for patient care and safety
Importance of Standardization
- Physicians agree that discharge summaries should have a standardized format 4
- However, there is no consensus on the level of comprehensiveness or format of the summaries
- Standardization can help ensure that discharge summaries contain all necessary information and are easily understandable by healthcare providers and patients
Audience and Content
- Discharge summaries should be written for both healthcare providers and patients 4
- However, there is debate on whether separate summaries should be created for patients and providers
- The content of the summary should include all relevant information, but also be concise and easily understandable
Challenges and Limitations
- Discharge summaries are often written by junior physicians who may lack experience or training in this area 2
- This can result in poorly written summaries that are unclear, inaccurate, or lack important details
- Efforts are needed to improve the quality of discharge summaries and ensure that they meet the needs of healthcare providers and patients