Exchanging Patient Records: 1

The Hospital End, Paper First

Before computerising a system for hospital discharges coming to GPs electronically (which we would like next week, please) sort out the existing paper one.

WRITING DISCHARGE SUMMARIES

GPs read hospital discharge letters with great interest. A well written one is always appreciated.

Most however are only fairly good. This is partly because the doctors producing them may have no control over the final appearance or disposition of the paperwork, partly because they have not been on the other end and partly tradition. House officers and SHOs are rarely told why the summaries are important outside the hospital, and it does not figure in the medical school curriculum. GPs requirements have moved on, partly driven by new technology and partly by the Deparment of Health's various ideas.

Discharge letters traditionally come in two parts, an initial quick handwritten note which must reach the next doctor to see the patient, before the patient arrives, to be useful, and a later formal typed letter which includes relevant tests and plans for follow up.

Hospitals now restrict the supply of drugs on discharge to one or two weeks. Patients usually attend five to ten days before these run out. Unless a good summary is received before then plans for treatment may not be carried out and considerable inconvenience and annoyance of GP and patient results.

The Medical division at the Royal Devon and Exeter Hospital took a grip on their summaries last year and now manage to produce a word-processed and therefore legible initial discharge summary within 24 hours of discharge. This has gained widespread praise and should be emulated.

Information recorded in the notes may be valuable to GPs, and now that many practices keep and search comprehensive computerised records, recording blood pressures, normal urine testing and ECGs, height and weight will be appreciated. So as not to spoil the flow of the narrative these should be appended as a table.

GP notes can easily become unmanageably full of duplicated records on untidily folded paper. Help in avoiding this will always be appreciated. Hospitals have never been keen on sending letters on A5, which fits GP notes with a single fold, but it would be helpful if they would, or if the information could be in an A5 area on the A4 sheet, then the excess paper can be trimmed off before filing.

The guidelines on pruning notes are that for any episode only one letter need be kept, but it needs to be comprehensive. Writing the final letter by editing the initial discharge letter without removing anything produces an ideal single report, and earlier versions can then be discarded. The ideal of course is to have the initial discharge summary and the report of operation or technical investigation both on the word processor, combine them, add a remark about follow up and print it. After attendance at the out patient clinic the final remarks can be added to this document and the GP receiving it can throw away the previous version. Done well this may take over from making a separate set of handwritten notes since it does their job as well.

Remember that the GP reading the letter may not be the GP who referred the patient. This applies particularly to emergency admissions. The letter is usually seen in isolation from the notes, so that an out- patient letter saying "He has improved and we will see him again in six months" may take up more time than you intend as the recipient calls for the notes to see what you were seeing them about. "His indigestion has improved" is more helpful.
It is helpful to refer to the original referral letter in the discharge summary. In an emergency referral the handwritten letter may not have a copy in the GP notes, and even if it does the carbon copy will be difficult to read, so adding the reason for referral will be useful. Every study of referrals shows that there are many specific questions asked in the original referral letter which are not answered in the reply. When I write "I would be grateful for your opinion on.." I mean just that and it is good to address this specifically.

A well-written discharge summary is very helpful to the next hospital doctor to see the patient, and the same features which help GPs will help them.

the best way to produce a timely, comprehensive and legible handwritten discharge note is to start writing it when the patient is admitted! Each significant item can be added as it becomes apparent. Sign and complete it as soon as the decision to discharge the patient is taken and try to persuade staff that it is important the form goes out with the patient rather than being put back in the notes and sent to the secretary. Lastly, tell the patient to make sure the note goes to their doctor, rather than to give it to them. Not all patients need a visit immediately after discharge, and certainly not solely to collect an envelope!

Training and audit.

Most however are only fairly good. Is lifted from the British Medical Journal article on how to get a paper published in the BMJ, which was reproduced in one of the "How To Do It" series of compilations which are excellent and useful. Available from the BMJ/BMA bookshop.