Discharge Summaries:
The discharge summary is the most important document produced during a patient's admission. It is used to communicate details of the patient's hospitalization, including diagnosis, work-up, and follow-up to the rest of the Mount Sinai community. Junior residents and PAs complete the discharge summaries on all of their patients. Patients should not be taken off of the provider's personal list until the discharge summary has been completed. If the patient is to be discharged over the weekend, the resident from the week should have the discharge summary mostly completed in advance so as to reduce workload for the weekend team. If the PGY-2 is not present at the time their patient is discharged (i.e., a weekend), they should ensure that the summary is completed when they return. When there is a team change, the outgoing team should pend discharge summaries up until the point of the service change. Occasionally, if a student or sub-I is serving as the “junior resident” for a patient under the supervision of the PGY-4, the student can generate/write the summary, but it is the PGY-4’s responsibility to edit, finalize, and sign it.
Once signed, the discharge summary is sent to the supervising attending to review and sign. Once signed, it becomes a permanent part of the medical record, and may be accessed months or years later by other residents and faculty. Completion and quality of discharge summaries are overseen by the attending of record and both the department and the hospital administration. Avoid putting anything in a discharge summary that you would not wish to be reviewed in such a way. If the attending feels that the discharge summary is inaccurate or insufficient, they will send it back to the resident to be revised. Doing it well the first time will save time in the long run! If a discharge summary is not completed, it can result in the attending being suspended. You may be contacted to complete a “delinquent” discharge summary; please complete these immediately to keep our faculty employed. PGY-4s are available to answer questions and assist juniors with discharge summaries at any time.
A comprehensive discharge summary should include the following items
A brief summary of why the patient presented to the hospital
Relevant neurological exam on admission
Admitting diagnosis and Discharge Diagnosis + etiology
A succinct but comprehensive summary of what happened to the patient while in the hospital including all tests and procedures, significant lab findings, all new medications, any changes in the patients symptoms or examination, any consultations with other services and their findings, and any adverse events
Discharge medications
Follow-up plan, including outpatient appointments and any follow-up testing required or medication changes that will occur after the patient leaves (eg. "to repeat MRI in one month" or "increase topiramate to 100 mg in one week if tolerated")
The following should be specifically avoided in discharge summaries
Bullet points or lists, except for medications
Day-by-day recounts of the hospitalization (eg., "spiked fever on Tuesday; UA pending") is appropriate for the signout, but this is absolutely not to be included in the discharge summary – it is a retrospective review, not a blow-by-blow account.
Any but the most common/universal abbreviations and acronyms (must be understandable to a non-neurology nurse, medical student, physical therapist or family care physician). For example, "PERRLA" is acceptable; "MAE" ("moving all extremities") is not.
Avoid using "unapproved" abbreviations - the ones that scroll across the screen of every computer in the hospital.
Scheduling post discharge clinic follow-up
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Stroke follow-up
Fellows clinic - email stroke fellows
Drs. Stein, Fara, Hao, Sheinhart - lola.poku@mssm.edu
Drs. Dhamoon and Tuhrim - katherine.garcia@mssm.edu
Dr. Ostojic - lilibel.perez@mssm.edu
Epilepsy Follow-up - e-mail attending and/or amanda.perez@mssm.edu
Email the following addresses for follow up appointments: Discharge.followups@mountsinai.org with the following information
MRN:
Name:
Insurance:
DOB:
Pt contact #:
Requestor contact name and number:
Dept & appt request time:
Reason/diagnosis:
Preferred MD (if relevant):
Anticipated d/c date: