We are working on a concept for improving our discharge letters. This involves both structural and stylistic improvements. Here are the most important points:
- The letter aims at the next care provider, the PCP mostly, but also the next hospital (including us if the patient is readmitted). It serves to convey the diagnosis (what?), a proof that the diagnosis is right, a very short description of the course (complications) of the treatment and a plan for future treatment. It should not serve as a notepad for daily events. It should not serve as a reminder for what to do on the next admission.
- Give a good but not exhaustive list of diagnoses, citing only those that are relevant for the current admission.
- Give a good and exhaustive history of current events.
- Give a complete list of clinical and paraclinical results, erasing all unnecessary remarks (“the result was conveyed to the treating neurologist”).
- Give 1-2 sentences that convey the diagnosis and a reason why it is correct.
- If necessary, describe the course of the patient over 1-2 sentences, mentioning only important events.
- Give a concise and exhaustive plan in bullets.
As for style I recommend this article.
- Avoid redundancy at all cost.
- Avoid set phrases such as “thanks for continuing the treatment”, “continue this treatment”.
- Avoid “The past medical history is presumed.”
- Avoid passive constructions, substantive constructions.
- Avoid medical jargon, e.g. “An oral anticoagulation was initiated with Rivaroxaban.” – make it simpler: “We gave Rivaroxaban.”
- … list could be continued