It’s 1AM, you’re a third of the way through your night shift. You finish at 7:30 but that seems a long way away. You’ve just seen a 25 year old male patient with some vague abdominal pain, nothing specific, and a normal examination. You don’t think it’s an appendicitis and you’re getting ready to discharge him.
At most hospitals you now have the option of creating a discharge information package for this fellow. It’s a document written by the hospitals medical staff and lawyers, usually many pages long, detailing every imaginable thing that could happen or go wrong. Usually it prints from the computer system and you fill in the blanks. It’s written in plain language, easy to understand as long as the patient has at least a pre-med degree.
Pre-printed discharge instructions are mostly useless. Most emergency departments place a waste container near the exit to handle these instructions as patients leave the building. Patients with wood-stoves or fireplaces may keep them to use as kindling, but they serve little other purpose. They are too long, too complicated, and too impersonal.
When you are discharging a patient, especially a patient with an uncertain diagnosis, do it yourself. Take a moment and sit at the bedside. Tell the patient that it is still uncertain what exactly is causing their problem. Tell them that you don’t think it is anything serious or life threatening or you would be keeping them in the hospital.
When you explanation is complete tell the patient; ‘There are a few things I want you to do.’ Then take out your prescription pad and write down a maximum of three discharge instructions. Three, that’s the number that most patients are going to be able to handle. If you need 15 instructions to get the patient home, the patient should probably not be going home, so you only get three.
Instruction number 1 is about time and place specific follow-up. ‘See your GP tomorrow morning.’ ‘See the orthopaedic surgeon next Tuesday.’ ‘See me, in the ER in 6 hours for a recheck.’ The person is specified, and the time is specified with no room for ambiguity.
Instruction number 2 gives situation specific cues for the patient to return to the emergency room immediately. Usually these are simple, if your pain is worse, if you have any weakness, if you are vomiting. This instruction always lists the place of follow-up as the emergency department.
Instruction number 3 always gives the same simple message; If you are worried, or if you think something is wrong, come back to the emergency department right away. We would be happy to see you again, anytime.
These instructions are simple and understandable. They minimize your medico-legal risk by minimizing the patients risk. They are personal, the patient knows that you created the instructions just for them, and just for this situation. Finally they are written on a prescription pad, a quarter sized piece of paper that only important things are written on.
Our patient has abdominal pain, maybe he has gas, maybe he has early appendicitis, the reality is that we just don’t know. So that’s what we tell him, and then we write a set of discharge instructions that list:
- Time and person specific follow-up
- Cues to return to the emergency department immediately
- An open invitation to return at any time if the patient thinks something is wrong or has any concerns
The chances are that our patient will be all better in the morning and go to work, instead of coming back for his re-check. But, for the occasional time that this patient will come back with appendicitis a good set of discharge instructions changes everything; instead of being the doctor who missed appendicitis, you will be the doctor who knew it might be appendicitis and arranged follow-up.