THE life of a foundation year doctor is by no means a quiet one. Whether you are clerking new patients, providing ward cover or managing your own team’s patients, the list of tasks to get done can seem endless.
One inevitable – and very important – job for all foundation year doctors is completing the discharge form. Whether your hospital uses an electronic system or remains with the more traditional hand-written form, most patients will need a completed discharge form before they leave the hospital.
You may be approached to complete discharge forms for patients at the end of a registrar or consultant-led ward round. Or you may be bleeped to be told that one of your patients is now fit for discharge. Perhaps the most disheartening situation is when you are on-call covering the wards and receive a bleep asking you to complete one (or often more) discharge forms for patients you have either never met or know very little about.
Bottom of the pile?
Foundation doctors quickly realise the necessity of prioritising their work based on clinical need. In most occasions it is simply not possible to complete jobs the moment you are given them. You may feel that patients needing discharge forms are fit to leave hospital and so they can wait until you have addressed the clinical needs of sick patients. Although no one could argue with your logic, patients and their families are often desperate to leave hospital as soon as they have been given the green light. It is therefore very helpful to inform ward staff at an early stage if you are swamped and won’t be able to complete a discharge form so that they can manage the patient’s expectations.
Some doctors take a different view. They consider discharge forms as “quick jobs” and are keen to clear them out of the way to make their task list more manageable. You may attend a ward to find several forms waiting for you and feel the urge to blitz through them at the same time as you re-write the endless prescription charts that have run out. There is some rationale to this approach – it will certainly enable ward staff to turnaround the bed more quickly, making it available for the next patient.
Whenever you feel the urge to hastily complete a discharge form it is worthwhile taking a moment to consider what happens once the patient leaves the relative safety of the hospital premises. From feedback we have received at MDDUS from GPs, the discharge form is often the only piece of information they have on the patient’s hospital care and treatment. You may have commenced some medicines and stopped others, or asked the GP to monitor or follow-up an outstanding issue. In the absence of a complete discharge form, a patient’s GP can only rely on the patient’s recollection of events, which we all know can often be very poor.
The extra few minutes you take to complete a discharge summary thoroughly can make a huge difference to the patient’s care after they leave your hospital. Unfortunately, GPs are under as much time pressure as hospital doctors and therefore often do not have the time to call hospitals to find out what treatment their patients received. It is therefore all the more important that their colleagues in secondary care provide them with all the relevant information they need to continue a patient’s care in the community.
The GMC also provides guidance to doctors in their core guidance Good medical practice (2014) which states at paragraph 44 that doctors “must contribute to the safe transfer of patients between healthcare providers … you must share all relevant information with colleagues involved with your patients’ care”.
When you complete and sign a discharge form, even if it is for a patient you don’t know that well, you are acting as the hospital representative responsible for transferring the ongoing care from secondary to primary care. You are accountable for the information you provide to the community doctor and any potential harm that may occur if you omit relevant information.
MDDUS has dealt with numerous cases where the misreading of a discharge form, or absence of relevant information, has resulted in patient harm. An example includes when a medication has been stopped, but no reason or explanation has been recorded on the discharge form. As a result it is not noticed by the GP who may have received a pile of other discharge summaries that same day. The patient could then receive a repeat prescription from their local practice including the omitted medicine.
Similarly, we have encountered cases in which patients have not been followed-up in the community following a new diagnosis or abnormal result because it has either been omitted from the discharge form or was illegible.
Although you may anticipate the GP will receive more detailed correspondence from the hospital after your discharge form, unfortunately this often either does not take place or is lost.
Many hospitals have their own proforma and guidance notes to complete discharge forms. Your hospital may also use an electronic system, which should reduce the risk of legibility difficulties, although you should be mindful of the additional risk of predictive text errors and ignoring popup messages about drug interactions.
If you are unsure how to complete a particular discharge form, consider consulting a senior team member to make sure you have included everything that the patient’s GP needs to know. The ward pharmacist and nursing staff are also valuable sources of information and support.
Help is also available from external bodies such as the British Medical Association or the Royal College of Physicians, which has useful guidance on record standards on its website. Section four of the RCP guidance provides suggested headings for discharge forms (both paper and electronic) and you may want to check your own form against this checklist. It also provides examples of what information, including relevant positive and negative findings, should be contained within each heading. If you find the boxes within your discharge forms are too small to fit all the necessary information, continue on an additional form. You should then number each form and indicate the total. This is much better than writing in a microscopic text to include everything on one form, which may be barely visible at all on the third carbon copy.
You have numerous demands on your time with colleagues asking you to do things as fast as you can to help them to do their job. In each case, try to make decisions that you are happy with, weighing up the need to provide a detailed discharge form with other clinical obligations and the wider needs of the hospital.
Dr Naeem Nazem is a medical adviser at MDDUS and editor of FYi