A discharge summary is a story

When I trained, my attendings read every discharge summary I wrote. If I had turned in a list of filled boxes, they would have handed it straight back, probably with a few words I won't repeat here.

The rule was simple: you have to put what happened in a story format.

Somewhere along the way, that rule lost to the template. A lot of summaries today are built to satisfy a metric, not a reader. Every field is filled. Nobody can tell what happened.

Who you're writing for

You're writing for a doctor who wasn't there. Often it's the primary care doctor, seeing the patient a week later, with fifteen minutes and a dozen other things to cover. They need three things fast: what happened, what changed, and what they have to do now.

A template can't tell them that. A story can.

The six parts

1. One opening line. Who came in, with what, and why it mattered. 2. What happened, in order. The turning points, not every day. What you tried, what worked, what didn't. 3. What you think, and how sure. The working diagnosis and what you ruled out. If you're not sure, say so. That's information too. 4. What changed. Every medicine started, stopped or changed, with the reason. Otherwise the next doctor may undo your best decision. 5. What's still open. Pending results and referrals, and the name of whoever owns each one. A result with no owner lands on nobody. 6. What to do first, and by when. The labs, the visit, the warning signs, with dates.

Does that make sense so far? Six parts, in that order, and most summaries fit on one screen.

Before and after

The template version:

Admitted for CHF exacerbation. Diuresed. Meds as above. Discharged in stable condition. Follow up with PCP.

The story version:

Came in short of breath with a heart failure flare after a week without her water pill; she ran out and couldn't get a refill. Responded to IV diuresis, down 4 kg and off oxygen by day 2. Echo unchanged from last year. Restarted furosemide at a higher dose (40 mg twice daily, up from 40 mg once daily) because she was still overloaded on the old dose. Potassium 3.4 at discharge, so we started a supplement. Pending: a magnesium level drawn the morning she left; our team will call her with it. She lives alone, so home health will visit twice a week. First visit within 7 days: weight, potassium, creatinine. She knows to call if her weight goes up 3 pounds in a day.

The second one is longer. It also saves the next doctor twenty minutes, and maybe saves her a readmission.

The habit

Write the summary the way you would tell it to the next doctor in the hallway. Then read it once as that doctor. If you would have a question, answer it on the page.

The chart is a legal record, a billing record and a quality record. Make sure it is still a medical one.

General educational content. Not medical advice. The patient described is a composite.