Discharge paperwork: what do your patients get?

[Lunah, MSN, RN]

In my former ED, we'd always give our patients discharge instructions, copies of any lab results, copies of radiology results, and copies of EKGs if applicable. We always instructed patients to take those labs/rad reports/EKGs to their docs when they follow up. In my new ED, we don't give them any results to take with them, which I think is completely silly. I was told that they are "part of the medical record," but I disagree. They are no more part of the medical record than the discharge instructions we hand them, a copy of which stays with the chart. Does this seem strange to anyone else?

So what do your patients get at discharge?

[Anna Flaxis, BSN, RN]

Our patients get canned DC instructions. Any labs or diagnostics are part of the EMR, and their PCP can look it all up on the computer.

[Lunah, MSN, RN]

What about patients whose physicians aren't local or who might not have access to your EMR system?

[Altra, BSN, RN]

No hospital I've worked in or where I've been a patient has routinely included lab or radiology results as part of ER discharge paperwork. There are exceptions -- such as when a patient will require follow-up with an orthopod not affiliated with the hospital system, as in the out of town example you cite. But truthfully ... if I sustain a fx while on vacation (one that does not need prompt surgical repair) ... the first thing my orthopod will do when I see him/her 2-3 days later ... is to x-ray it again, even if I have films with me, so that he can examine the condition of my poor extremity in real time ... not the alignment of the bones 2-3 days ago before splinting.

I'm not sure I see the value in routinely including these results -- it seems like a LOT of wasted paper. How many patients will promptly follow up with a PCP if their symptoms are resolved? And even there is prompt follow up ... are the lab results of an acute episode of some sort necessarily useful once that episode is resolved?

What I do like to see is when our ER docs send the patient home with a script/order for follow up lab work for one week later or whatever time period is appropriate. That script, IMO, strongly encourages follow up.

[Anna Flaxis, BSN, RN]

Then their physician's office can have the records faxed to their office. What physician's office doesn't have a fax machine?

*Technically*, that information is part of the patient's chart, and thus *technically*, the patient is required to submit a request to Medical Records if they want copies of anything contained in the chart.

[FancypantsRN]

Our d/c paperwork doesn't typically include any labs or radiology results either, unless the pt requests it from the doc, then they get copies and rad/ct discs. Otherwise it is just the generic printout with dx and who to follow up with.

[RNChristy]

The hospital that I worked at did not send labs, xrays, etc. with the patients routinely either, because they ARE part of the medical record. If the patient or doctor wanted that info, they would need to call the medical records dept.

[AggieNurse99, BSN, RN]

Where I work I float (not critical care or ED) but inpatients never get labs without a release of info but outpatients can have labs without it. Crazy.

[crb613, BSN, RN]

No results...just generic dc instructions. If the pcp is not on our computer system then they will need to request them from medical records.

[KayRN910]

Just like the others, we give a print out of d/c instructions. I will give a copy of labs or whatnot if they request it, but honestly I dont think most people want them.