VCU Internal Medicine Training Program
Discharge Dictations - Expectations
- Resident supervision:
For the first 3 blocks, the team resident is ultimately responsible for making sure Discharge Dictations are done, and that they are of a sufficiently high standard. This generally means that residents should be doing most if not all of the dictations on behalf of the interns. It is acceptable for interns to start doing some dictations, and if they are particularly comfortable with doing this, they may assume this as one of their tasks. If interns are doing dictations, it is important for the team resident to really provide some expectations and feedback on this process and give specific guidance. Just remember, for the first three blocks - the team resident should be helping out with this in a very active fashion. - Timeliness:
Dictations must be completed within 7 days of discharge. Our medical records department keeps a close eye on this and we in turn send out emails to let you guys know who has surpassed that time limit. Please do not disregard this email as being unimportant. Your attending WILL have their privileges suspended if those dictations are not done in a timely fashion, and that is really an unpleasant outcome for all concerned. We do put letters of professionalism in your personal file if you do not get the dictation done within 7 days of being notified by us. Remember, at that point in time 14 days have elapsed between the patient going home and the dictation still not being done. We know you guys are busy taking care of patients, and that really does come first, but discharge dictations are an important part of documentation and overall patient care. They are a fact of life - please get them done in a timely fashion. And if a chief calls you to let you know that you are cutting it fine with the deadline, please take that seriously and make every effort to take care of the dictation. We don't like writing letters, so please help us out with this. - Quality and Content:
Whenever you do a discharge summary - put yourself in the position of a night float intern or resident who is admitting the patient as a bounce-back. We all hope that our patients will do fine when they go home and never have to come back to hospital again, but it is another fact of life that patients do sometimes bounce-back - for the same reason as the first visit, or for a new reason. As you are writing the discharge summary, really focus on thinking about providing sufficient information such that your night float colleague could quickly get up to speed on what happened during their last admission and start taking care of that patient. Arm them with the information you'd want them to have about that last visit. Here is a quick list of the bare minimum that we expect:- Admission date, team, attending, resident and intern
- Discharge date, team, attending, resident and intern
- Admitting diagnosis (e.g. Altered mental status)
- Discharge diagnosis (e.g. Bacterial meningitis)
- Secondary problems
- Invasive procedures
- Consults obtained
- Admission H&P - key elements of HPI, SH, home meds, vitals on admission, pertinent exam findings
- Key data from studies (labs, xrays)
- Hospital course (by problem or diagnosis) - this should include a summary of the key aspects of this patients care, even if they were only on a medicine service for part of that visit. As the discharging clinician, the onus is on you to describe briefly the key aspects of their hospital course from admission to discharge. It does not have to be a full recount of every note in the chart, but you should allow the reader to easily follow the trajectory of that patient from the time they got admitted to when they went home.
- Discharge medications - really important!!!! - we've all had patients that come in and tell us about their little white pills, and the rectangular yellow ones, and the odd looking blue one, and that they sometimes sort of take them but they're not too sure... it sounds familiar right? In the middle of the night, YOUR discharge dictation could be the one beacon of light that glows through the darkness to shed light on the mystery of what medications your patient is supposed to be on. Please do not leave this out and make sure it is accurate!
- Follow-up: please give an account of what your plan is for follow-up. Who is the PCP and when do you want the patient to see them next? What subspecialty appointments are you going to make? Is the patient going home or to rehab?
- Dictation Cards:
You guys should all have one of those laminated cards that tells you exactly how to access the dictation system. It also spells out the requirements listed above, so that will be a helpful reminder to you. If you have lost it or never got one, they are available in the dictation room out the back of medical records. For those who have never been down there, here's how to get there. On the way out to the D-Deck parking, turn right when you get to the scrubs machine (instead of turning left and going to your car), head down the hallway and WAY down on the left you'll find the door to medical records. You'll need your ID card to swipe yourself in, and then one of the friendly medical records staff can direct you to the back room. There are plenty of cards back there, so make sure you have a current version.
That's about all for now. Remember: knowledge is power! Arm your colleagues with plenty of knowledge about your patient. Don't assume the medical record from last admission will be readily available to them - your discharge summary really counts!
Happy dictating!
