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Patients need clear advice on what to do after hospital stay

February 3, 2008 12:16 am

AN OPEN LETTER to doctors on the well-being of patients being discharged from hospitals:

Dear colleagues:

Help!

I know we're all busy, and I hate to add to your burdens, but the discharge process employed at most hospitals is inadequate.

Innumerable patients are coming to me--and I suspect other primary doctors as well--having been recently discharged from hospitals without adequate knowledge of how to continue the health improvements achieved by their inpatient stays.

I know we all think we adequately explain things to our patients, but doctors, it just isn't coming across. We all look upon ourselves as healers, but the word "doctor" is defined in Webster's dictionary as "teacher." If we're not teaching our patients how to take care of themselves, we're failing in our primary responsibility.

My criticism is centered on the Discharge Instruction Record given to patients at discharge. (Patients, this is the sheet that lists the medications you are to take, follow-up treatment you are to get and other recommendations you are to follow after leaving the hospital.)

Doctors, please consider making the following changes when you fill out these sheets:

A handwritten sheet may be inadequate because it is illegible. I needn't remind my colleagues that most of us flunked penmanship. Discharge instructions need to be printed, preferably typed.

Do not use abbreviations, especially Latin ones. As a doctor I know what you mean, but the instructions are for the patient. Please, use plain, common English. "QD," "QID," "Q12H," "PO" and "QHS" mean nothing to my patients (though doctors know "QD," for instance, means to take a medication every day).

Never write a prescription or instructions that state "Take as directed." Believe me, I wouldn't remember from your examining room to my car what that meant. Can you imagine the chance for error if you gave me four prescriptions, all with instructions to "Take as directed"?

Also, spell out all medications. I know what drugs HCTZ, ASA, INH and FeSO4 are, but does the patient?

Indicate the dosage clearly. If instructions are handwritten, make sure "mg" is not misinterpreted as "mL." Use Arabic numerals, not apothecary symbols. (Better still, have the form printed out.)

Please indicate the reasons that all drugs are to be taken. The more information you can put on the pharmacy label, the better. It helps the patient and the family understand which drug is for which condition, and may even help the next doctor understand the patient's problems.

A label for warfarin that reads "Take one daily to prevent blood clots from atrial fibrillation" or "Take one daily to treat blood clots in leg" gives much more information than "Take one daily to thin blood."

Please reconcile all medications, preferably with clear lists that indicate the medicines the patient was taking at admission and the ones to be taken at discharge.

Any drugs the patient came in with, on the first list, that are to be stopped should clearly state "stopped" on the second list, not "discontinued" (patients aren't sure what that means)--and certainly not "d/c." New drugs should be designated "new" in the second list. Dose adjustments should be clearly indicated in the second (going-home) list as "increased" or "decreased" from the first list.

Try to use the drug name the patient is most used to, whether it's a generic or trade name. If the patient has been taking "warfarin" at home, and you give a discharge prescription for "Coumadin," will the patient think they are two different drugs, take both, and suffer a potentially serious overdose?

If patients need to follow a special diet, will they know what "cardiac," "low fat" or "liquid" means if you don't give a separate diet sheet with specific guidelines?

Again, please, no abbreviations. "NAS" or "NCS" won't convey any useful information, and I'm not even sure what you mean, so spell out dietary restrictions, rather than writing "No Added Salt" or "No Concentrated Sweets."

Please make sure it is clear to the patient who, exactly, they are to see in follow-up; if possible, make the appointment for them. If any follow-up laboratory testing is necessary, make sure instructions are precise as to the test, the reason for it, who is to get the results, and again, please, no abbreviations. Write "protime," not "PT." Writing "Get a protime to test thinning of blood from warfarin at hospital lab on Thurs., Jan 31, with results to be called to Dr. Bley" leaves little to interpretation.

Thanks! I know I've asked a lot, but consider that the patient is your elderly, widowed mother. Wouldn't you want her to have the best discharge instructions possible?

Dr. Donald E. Bley was a family practitioner in Fredericksburg for 25 years. He also spent four years as a hospitalist at Culpeper Regional Hospital.