Reconocimiento de responsabilidad y aceptación pública de los hechos

Patients are the main subject in discharge summaries, and the content and presentation of discharge summaries is largely influenced by the characteristics and complexity of patient problems and the manner of their admission. Firstly, how a patient is admitted to hospital may influence the way the discharge

summary is written. For example, if a patient is admitted through the Accident and Emergency Department with new symptoms there may be a lot of information to put in his/her discharge summary. On the other hand, if a patient is admitted for a planned operation and is discharged immediately afterward, the content of his/her discharge summary is likely to be brief:

“An acute patient who just comes in off the street and come in with a totally new symptom, you need to write down what he came in with, you need to write down whether there were any complications, you need to write down the progress. Whereas if you had somebody who has an operation and he’s going to be discharged, say within a few hours, you’ve got no time to write complications and progress, but because you haven’t had time to develop any of that.”

(Consultant 10 in Simulation Interview)

Similarly if a patient’s episode of care is short, both the TTO and the full

discharge summary tend to be quite short and have less information. On the other hand if a patient stays in the hospital for a long period of time, the discharge summary tends to be long in order to capture the different problems and key incidents, interventions and tests during the patient’s episode of care. This account was described in the following exchange:

I: And can you tell me what might be the main difference in the way you create TTO compared to the dictated one.

R05: I think if it’s been a short admission, there’s no difference, you know, because there’s not much information to give. If somebody’s been in for a long time, or especially in elderly wards, they can be in 6 weeks, 3 months, you know anything, quite a long time, and then on the TTO you’ve not got room to put all the different problems that arose, so you just put the main diagnosis and then when you do the dictated one, you give them a bit more information, explain why it was such a long admission, explain the problems that occurred and all the test results and things.

126 Secondly, the level of complexity of patient problems and complications may also impact on the degree of elaboration in the discharge summary. If the patient problem is simple and routine, the discharge summary tends to be straightforward. On the other hand, if the patient has many complications, the full discharge

summary tends to be longer and more elaborated:

“So older people have more problems and are more complicated and need bigger discharge summaries.”

(Registrar 04 in General Interview)

Thirdly, the risk profile and disability associated with a patient often requires extra consideration for the follow up treatment plan, and this would normally be reflected in the discharge summary. For example, elderly patients may have a certain level of permanent disability associated with decreasing physical mobility and cognitive functions due to the ageing process.

As a result, an elderly patient is more likely to be followed up with additional supportive care in addition to, or instead of, follow up in an outpatient clinic:

“ I mean a lot of elderly patients, we won’t follow up in clinic because it’s quite arduous for them to come to the hospital for an appointment. So unless there’s a specific reason, like you want to review treatment or you want to repeat blood tests, then we wouldn’t.”

(Registrar 05 in Simulation Interview)

On the other hand, because of the high risks associated with the deficiency in their physical and cognitive functions, the information regarding the condition of these functions is likely to be featured in the discharge summary. Normally, this

information goes on the full discharge summary rather than to the TTO. This was offered in the following account:

“Some, especially elderly people you’d put in the discharge letter something about their mobility, their incontinence, their cognitive function, all that goes in the, in a dictated summary. But there isn’t room to put that on a TTO.”

127 Patients with a specific risk profile may also require specific follow up treatment. For example, a patient following a cerebral vascular accident (CVA) has a high risk of another incident. On patient discharge, an outpatient clinic follow up is often arranged. This follow up is necessary to educate the patient as part of secondary prevention. Hence, an outpatient clinic follow up is pretty standard for a patient admitted for the first episode of CVA:

“Erm, I think so, I think certainly stroke patients, we usually tend to follow them up to discuss the sort of secondary prevention. So to go, because obviously sometimes there’s quite a lot of information for them to take on board at once. So by the time you’ve got home, you can check the blood pressure and you can check what medication they’re taking, things about stopping smoking, if they were drivers, you can discuss whether they can go back to driving, so three months is probably about right for somebody who’s had a stroke."

(Registrar 05 in Simulation Interview)