Discharge documentation

Background

• Discharge documentation is a critical component of the ED medical record
• Inadequate discharge instructions are a leading cause of ED-related malpractice claims
• EMTALA requires that patients receive discharge instructions and a plan for follow-up care
• Discharge documentation serves dual purposes: patient safety communication and medicolegal protection

Key Elements

• Diagnosis (or working diagnosis if uncertain)
• Condition at discharge (e.g., improved, stable, unchanged)
• Medications prescribed with dose, frequency, duration, and purpose
• Follow-up instructions with specific timeframe and provider
• Return precautions — specific warning signs that should prompt immediate ED return
• Activity restrictions if applicable
• Work/school note if requested
• Patient understanding documented (verbalized understanding, teach-back)

Return Precautions

• Return precautions should be diagnosis-specific and clearly communicated
• Generic "return if worse" is insufficient — specify what "worse" means
• Document that return precautions were given by the physician personally
• Consider language barriers and health literacy; use interpreter services when needed

Sample Documentation

General Discharge

The patient has been evaluated, treated, and is being discharged in improved/stable condition. Diagnosis, treatment plan, medications, activity restrictions, and follow-up have been discussed with the patient. The patient has verbalized understanding of the discharge instructions and return precautions. The patient has been instructed to return to the Emergency Department immediately if symptoms worsen or new concerning symptoms develop.

Discharge with Uncertain Diagnosis

@NAME@ has been evaluated with history, physical exam, and appropriate workup. At this time, the most likely diagnosis is ___. However, a definitive diagnosis has not been established. The patient has been counseled that their condition may evolve and that additional evaluation may be needed. Specific return precautions have been discussed including ___. The patient has been instructed to follow up with ___ within ___ days for re-evaluation, and to return to the ED immediately if ___.

High-Risk Discharge (e.g., Chest Pain, Abdominal Pain)

@NAME@ has been evaluated in the emergency department. Based on today's evaluation, I do not believe the patient has an immediately life-threatening condition. However, the patient has been counseled that today's evaluation does not exclude all possible diagnoses and that symptoms may represent an evolving process. The patient has been instructed to follow up with ___ within ___ days. The patient has been given specific return precautions and instructed to return to the ED or call 911 immediately if symptoms recur, worsen, or new symptoms develop including ___.

Discharge Against Medical Advice

See: Against medical advice

Common Pitfalls

• Failing to document who received the discharge instructions (patient, family member, caregiver)
• Not documenting specific return precautions tailored to the chief complaint
• Omitting follow-up timeframe or provider
• Not addressing medications the patient was taking prior to the visit (held, continued, changed)
• Discharging without documenting a reassessment (see Reexamination sample documentation)

See Also

• Documentation for emergency physicians
• Against medical advice
• Reexamination sample documentation
• MDM for different chief complaints
• Differential diagnosis documentation

Documentation Pages

• General
  • Documentation for emergency physicians
  • Billing
• Components of the Medical Record
  • Review of systems documentation
  • Physical exam documentation
  • Differential diagnosis documentation
  • MDM for different chief complaints
  • MDM for different chief complaints (peds)
• Procedure and Reexamination
  • Procedure sample documentation
  • Reexamination sample documentation
• Special Documentation
  • Critical care documentation
  • Observation documentation
  • Against medical advice
  • Discharge documentation
  • Death documentation
  • Informed consent documentation
• Reference
  • Ophthalmology abbreviations