Discharge Summary

Overview #

• Write the summary you would want to read – succinct, highlight relevant details, clear accountability for follow up
• Follow the Discharge Checklist first – it will ensure that information is correct
• Fix chart errors permanently: If you need to fix something that pre-populated, fix it in the chart and refresh the document – don’t leave the error in the chart
• If a section is blank, it will automatically delete. Manually delete sections with no-information text (e.g. “No Goals of Care Documented in CST Cerner”)

Admission date and time #

Pre-populates

Discharge date and time #

If not known, write ‘to be determined’

Admitting diagnosis #

Remove this section (leave blank)

Most responsible diagnosis #

• The diagnosis that cost the most to treat
• Will usually be the stroke, occasionally a complication following stroke (e.g. STEMI)
• Use common names with full spellings, and provide detail about localization, etiology, and treatment
  • Ischemic stroke, left MCA, secondary to atrial fibrillation, status post EVT
  • Intracerebral hemorrhage, left lentiform, secondary to hypertension

Diagnoses for this visit & Chronic Problems #

Pre-populates based on Discharge Diagnosis mPage component – make your changes there

Tag as This Visit + Chronic #

• Ischemic stroke / intracerebral hemorrhage
• Long term comorbidities e.g. atrial fibrillation, hypertension, diabetes
• Issues that require follow up (e.g. lung nodule) – use display as (e.g. Lung nodule, left lower lobe, for CT chest 2024 by GP)

Tag as This Visit #

• Complications that required more than trivial management (e.g. include a significant delirium, leave out UTI)

Tag as Chronic #

• Past medical history that wasn’t relevant to hospital stay

Advance care planning #

Delete if “Advance Care Plan: No…”

Goals of care #

Delete if “No Goals of Care Documented in CST Cerner”

Code status #

Pre-populates if ordered. If not ordered document reason why or clarify prior to discharge / transfer

Operative interventions #

• List of invasive procedures done during the hospital stay
• Although prepopulated in template, data quality is poor and records are locked – this is one to fix in the discharge summary
• Includes surgeries, EVT procedures, stenting

Procedure/Surgical History #

Intended to be a lifetime list of procedures – unless you are entering this data, delete this section and anything it contains

Other interventions #

• Thrombolysis
• Mechanical ventilation

Primary care provider #

• Should pre-populate
• If pre-populated, that means that the primary care provider is correctly coded in Cerner, and will automatically get a report
• If the pre-populated name is incorrect or missing, send a Unit Clerk Communication Order to request an update
• Adding a name here does not distribute the report, if the primary care provider isn’t correctly pre-populated, they will not get a copy unless you correctly send a copy at signature

Names of relevant specialists #

• You are writing this so people know who is involved – adding a name here does not distribute the report – to send report you must correctly send a copy at signature
• Suggest including
  • Admitting Stroke Neurologist
  • Follow up Stroke Neurologist
  • Discharging Stroke Neurologist
  • Any other specialist that was key / would benefit from being copied onto discharge / will follow up at discharge: Interventional radiology, rheumatology for vasculitis cases, endocrinologist that will follow as outpatient etc.

Allergies #

Pre-populates – correct any errors using the Allergies module

Medications #

• Pre-populates based on discharge medication reconciliation
• Planned transfers: write “Interim discharge summary, medication reconciliation to be done on day of discharge”

Immunization administered #

Pre-populates

Lab results #

Delete irrelevant pre-populated labs -and add in relevant labs using tags

Functional history #

Patient function prior to hospitalization, function at transfer / discharge (e.g. Patient lived alone and was independent prior to hospitalization. He currently is an overhead lift and requires assistance for all iADLs and ADLs)

Hospital course #

• Brief temporal course for each important diagnosis treated in hosptial
• Complex patient: 2-3 sentence overview of big picture events, then dive into issues

Delivery measurements #

Leave blank to delete

Significant findings #

• Results that allowed me to confirm the mechanism of stroke and monitoring of stroke
• Synthesize essence of report (e.g. Echo – no source of embolus; mild left atrial enlargement; not Normal LV, Normal RV, Normal PASP, etc. ; CT-CTA – acute left MCA ischemic stroke, M1 occlusion, good collaterals with penumbra; thyroid nodule for follow up)
• Include details of incidental findings that need follow up (e.g. specifics of a lung nodule)

Procedures and treatment provided #

Record information in Operative Interventions / Other Interventions, leave this blank to delete

Discharge disposition #

• Home
• Home with supports
• Home with outpatient rehabilitation
• Inpatient rehabilitation
• Long Term Care Facility 
• Repatriation to home hospital
• CAMU

Note: It is better to not mention particular names for PTN (Patient transfer network) or rehabilitation since these may change