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 reduce morbidity and mortality in patients with diabetes. When creating a discharge summary, it is essential to include the patient's demographic information, admission and discharge dates, principal diagnosis, secondary diagnoses, procedures performed, medications prescribed at discharge, follow-up care instructions, and the physician's signature 1. The discharge summary should also review and address the following areas of knowledge before hospital discharge:
- 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
- Proper use and disposal of diabetes supplies, e.g., insulin pen, pen needles, syringes, and lancets 1. Scheduling follow-up appointments prior to discharge with people with diabetes agreeing to the time and place increases the likelihood that they will attend, which can improve quality of life and reduce morbidity and mortality 1. It is crucial to prioritize the transmission of discharge summaries to primary care clinicians as soon as possible after discharge to ensure timely follow-up care and reduce the risk of complications in patients with diabetes 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