I just read a discharge summary that was so wrong that it got me angry. Among the grievances I had with it:
--alternated between calling a bleed in the brain a subdural hematoma and subarachnoid hemorrhage
--did not say what side any of the patients fractures were on
--at one point, it just said the patient had a compression fracture, but didn't ever say where
--wrote that patient got fresh frozen plasma in the middle of her hospital course but did not say why
--said that the patient needed a lumbar brace at all times when the patient did not need it at all
--got the patient's weight-bearing status wrong, and failed to even say what side they were talking about
I don't expect for everyone to document everything like a medical student would, but at least put in a seed of information that I can use to treat the patient. There ought to be a place where you can report somebody writing such a terrible discharge summary.
Welcome to my world - the world of medical records that are contradictory, senseless, inane, and just plain wrong! At least I don't have to plan patient care based on the record, I just have to figure out whether the doctor met the standard of care. Tricia
ReplyDeleteI would argue that this is what happens when you're forced to document stupid things most of the time. Then when it's actually important things like this happen. Only, I don't know if that's actually true....
ReplyDeleteThis one has many egregious errors, but it seems that many consider the d/c summary to be an afterthought. It's true we're not specifically paid to do it and have enough to do taking care of current patients. There's no reward for good d/c summaries (other than the knowledge that I did a a good job) nor any punishment for bad ones. I got lots of positive feedback on the summaries I did during residency, but it took a long time for me to make them accurate and comprehensive.
ReplyDeleteIn addition, some states require a d/c summary to be included with transfer records, but I did my rehab training in a state that didn't require this. Admitting patients with often incomplete transfer records is not only a hassle but bodes poorly for patient care. I frequently had to call transferring hospitals for critical information like med lists, current INR, whether anticoagulants/antibiotics/BP meds were given before transfer, and mental status prior to d/c (for when patients arrived arousable only to sternal rub...good times).
I had a patient while I was in the PICU as an AI who I meticulously wrote-up a discharge summary for, explaining her overall course and complications she faced. She got transferred to the floor after I left, and the AI who picked her up discarded my whole summary and wrote like 3 lines to justify the reason she was in the hospital, not mentioning the reason for the extended stay or any of the complications she faced in the PICU. It was one of the most useless d/c summaries I've ever read.
ReplyDeleteYou could probably report it to the Joint Commission or CMS. Or take it up with the chief and have it put on the OPPE report.
ReplyDeleteForgive my ignorance but is there a standard format for discharge summaries and
ReplyDeletethe like? Just curious.