Writing a discharge summary is a task you are likely to carry out every day, and despite the sense of monotony, it plays a critical part in the patient journey.

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Contents of a good discharge letter

Writing a good discharge letter starts with understanding what purpose it serves.

• This is the only piece of information the GP receives about your patients’ entire admission (anything from 1 day to many months). They need to have an understanding of key events & decisions that occurred.
• Provides the same information for the patient and their relatives to digest in their own time, as well as an idea of what to do (or not) and what to expect next, both in terms of recovery and follow up.
• Forms a prescription for the pharmacy team to dispense medication on discharge.
• The medication list will also be used to update the patients repeat prescription by their GP practice.
• Allows future colleagues or ambulance services to understand what occurred during a patient’s last admission.

GP’s are too busy to read War and Peace, and you’re too busy to write it. Finding the balance will come with time and experience, but do NOT copy the entire text for every scan or put every blood test result.

When including important results remember the patient will get a copy. Whilst they should know the results, consider your wording.

Make it clear what tests or results are outstanding – do NOT ask the GP to chase them up. All tests requested or carried out in hospital should be done under the name of the responsible consultant. This means the result will be sent to them for further action.

Document critical self-management information for the patient or their relatives. E.g.: advice about driving, flying or weight-bearing, safety netting

You MUST provide a sick note covering the entire period the patient is not expected/advised to work. Note that people can self-certify for 7 days. It is not acceptable to ask the GP to do so and they are no longer contractually expected to do so.

There are certain actions you will need to ask the GP to carry out. Most discharge letter templates have a designated section for this. Make sure you use it, as during busy periods the practice may triage their large volume of incoming letters based on whether there are actions required.

Document follow up plans clearly (which consultant and approx. time frame), check these with your seniors. Make sure there is a process by which the appointment will be made. They are sometimes done by a ward clerk based on what you have written, which is why clarity is key.

Prescribing

Prescriptions should be clear enough for the pharmacist, patient and GP to understand. Common errors to avoid are:

• Inaccurate prescription of controlled drugs. Remember to use words & figures, the correct form (tablets/capsules/liquid) and state how much you want to be supplied.
• If your hospital has electronic discharge letters find out if you need to print and sign a copy if they operate a separate prescription pad or other. You WILL need to provide some form of a signed document.
• Every hospital will have a process for discharging patients who are on warfarin.
  • Items for you to consider are: what dose you want them to take on discharge, how long to do so before getting their next INR and who will be performing the blood test/acting on it. Do you need to make a referral to a specialist clinic?
• Antibiotic prescriptions should have a clear stop date. If the patient is going onto longer-term antibiotics (TB, osteomyelitis) be clear about who is managing this.
• You MUST provide details on why any medications have been stopped or started. Again, what you write down is the only piece of information a GP will have to turn to if the patient has any queries or a review is needed.
  • E.g.: if you stop an anti-hypertensive and the patient has a high BP at their next GP visit, how will the GP know whether to simply restart it? Did the patient have an allergic reaction or was their blood pressure on the lower side whilst they were unwell?
• If a district nurse will be administering any medicines there is often an additional form or authorisation letter to complete. Check with your nursing/discharge team.
• Try and avoid supplying paracetamol or ibuprofen (particularly long term) as the cost to the NHS is significantly higher than the patient purchasing it from a supermarket.

Additional points to consider

Any limitations on treatment that have been discussed should be documented for colleagues to refer to down the line.
E.g.: decisions around resuscitation, suitability for acute non-invasive ventilation.

You can turn discharge letters into an opportunity for work-based assessments.
E.g.: ask a senior colleague if they will read and comment on the quality of your written communication skills.

Start prepping the letter as early as possible after admission.

• Complete the letter the day before their expected date of discharge if at all possible (or at least their medication). This gives pharmacy time to prepare the medication in advance and might get your patient out of the hospital in time for lunch.
• Certainly aim to do them as soon as you can after the ward round. This is a key part of reducing ambulance queues and long A&E waits. No one can get in unless there is a timely flow out.

Example

An example discharge letter is included below.

Please note that different hospitals will have different formats and sections to complete – you will just have to complete the sections specified for you. However, in general they will include: patient details, clinical narrative, recommendations for the GP and medication on discharge. Often, they will include sections for investigation results, information given to the patient and follow-up.

Written by Dr Ruwani Rupesinghe (SpR) & Dr Katherine Charles (GP)