In the emergency department (ED), failure to comply with discharge instructions has been associated with an increased rate of adverse outcomes for patients. 1,2 There is tremendous variability in the information that is provided to patients in discharge paperwork. In some EDs, a simple handwritten discharge note is given to the patient, while in others, extensive, diagnosis specific pre-created instructions are provided to patients at time of discharge. To improve patient outcomes and reduce their medicolegal risk, providers must recognize pitfalls associated with discharge instructions and include two key elements as a part of all discharge paperwork.
Written instructions can be problematic
Written discharge instructions are often poorly understood and in some instances may increase a provider’s medicolegal risk. Multiple studies have demonstrated that patients have difficulty understanding their discharge instructions from the ED. In a study population where 65% of patients reported a college or post-graduate level of education, Engel et al. found that 22% of patients had difficulty understanding their discharge instructions. Despite high rates of poor understanding, only 30% of patients recognized their deficiency in comprehension. 3
There is little evidence to suggest that computerized, disease-specific instructions are superior to a more generalized set of instructions. Lawrence et al. compared custom hand-written discharge instructions to computerized, disease-specific instructions and found no association between the type of discharge instructions provided and the rate of return visits over a 72-hour period. 4
Written discharge instructions may expose providers to additional medicolegal risk. In an ED where busy providers often rely on pre-formatted disease specific discharge instructions, a simple error in printing instructions may have serious downstream consequences. For instance if a provider or a scribe printed instructions for gastroenteritis rather than for unspecified abdominal pain, these instructions could be used to support a claim of misdiagnosis in the event that the patient has an adverse outcome.
Provide and document verbal discharge instructions
To mitigate some of the limitations of written discharge instructions providers should provide and document verbal discharge instructions in addition to any paperwork that is provided. The importance of verbal instructions was emphasized in Celelland V. Haas. Despite clear limitations in the written discharge instructions the court stated: “once these documented instructions were supplemented with the additional verbal instructions…the discharge instructions as a whole did not fall below the applicable standard of care.” 5
A statement such as: “Additional verbal discharge instructions were given and discussed with the patient.” Should be included in the chart of all patients who are discharged.
All discharge instructions should include address two key elements
- Information regarding follow-up.
- Signs and symptoms that should indicate the need to return to the ED.
Most discharge instructions include specific medication instructions; however, this will be covered in a separate post.
Follow-up should be time and action specific
Providers should provide a clear time frame for patient follow-up. Repeatedly, courts have maintained that providers should not fully rely on the patient to determine the appropriate timing of their follow-up care. In Hill v. Wilson, a patient was discharged with a lumbar wound and was instructed to “Make an appointment with a plastic surgeon when available for treatment.” The patient scheduled a follow-up appointment in two weeks but unfortunately decompensated and returned to the ED one week after discharge. The appeals court ruled that the provider should have emphasized the need for expedient follow-up rather than relying on the patient to determine the appropriate interval for follow up care. 6 Statements such as “follow-up as needed” offer little in the way of guidance for the patient and protection for the provider.
Conversely, in a separate case, a patient was diagnosed with gastroenteritis and was instructed to follow up with their doctor within 2 days. The patient failed to follow these instructions and eventually returned to the ED 7 days later with perforated appendicitis. The patient required extensive surgical intervention and sued the ED provider. Fortunately, the jury ruled in favor of the doctor and the hospital. 7
Follow-up should also be action specific. For instance, in a patient with persistent pain overlying the scaphoid, it may be more appropriate to instruct the patient to follow up with an orthopedic surgeon rather than instruct them to follow up with their primary care physician. Not all patients need to follow up with specialists; however, the ED provider needs to make an effort to ensure that he or she is instructing the patient to follow-up with an appropriate provider when appropriate.
Return instructions should be open-ended
Previous court cases have found that patients should not be expected to accurately diagnose their own illness or recognize that they were getting worse. In one instance, a patient discharged with a finger sprain was instructed to follow up as needed with his doctor but was not given clear information in terms of the need for follow-up. Several weeks later when they continued to have issues with range of motion, they were seen by a hand surgeon and were diagnosed with a tendon injury. The patient sued the ED provider alleging that the instructions they received were not adequate and that they were not responsible for recognizing specific symptoms that signified that they were getting worse. The jury returned a verdict for the plaintiff and awarded $110,000. 8 Ultimately the patient has some responsibility to recognize if they are getting worse; however effective return instructions should utilize plain, easily understood language that encourages patients to have a low threshold to return seek care or return to the ED.
A phrase such as, “patient asked to return to the emergency department immediately for any new or concerning symptoms or if they get worse” can cover a broad range of pathology and gives parameters for returning that should be understood by a broad range of patients without relying too heavily on their ability to diagnose themselves or recognize specific symptoms.
Bottom Line
Adverse events after discharge from the ED are associated with bad outcomes for patients and increased medicolegal risk for providers. 9 Discharge instructions exist in an effort to improve patient outcomes. When providing discharge instructions, providers should give written and verbal directions that emphasize time- and action-specific follow-up instructions and provide nonspecific, easily understood return precautions.
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