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Discharge Instructions ---


Don't Just Show Them The Door!


   How are discharge instructions done, and by whom, at your workplace? When it's busy, do you find yourself "rushing" the teaching? Have you noticed some individuals seem better at teaching patients than others? How can we better benefit the patient, ourselves, and the E.D.?

    Discharge planning and assessment of homecare capabilities and knowledge deficits begin with the patient's arrival. The patient's ability to recount history and level of evident comprehension of his health state and ability to self-manage is given in verbal and non-verbal cues from the first moments of assessment. Discharge teaching begins with the first interaction with the patient and continues until after he is gone. 

    Our E.D.'s old discharge instructions (no longer used) were hand-written by the physician in a small box at the bottom of "the Doctor's sheet" and the last carbon copy was given to the patient. This led to several evils. The doctor's notes and lab results often ran over into the small space available. The harried physician often wrote in "medicalese" abbreviations. The patient's copy was often illegible. There was no room for adequate information to be given. There was no verifiable evidence of the prescription given. Different physicians gave different, sometimes inadequate, instructions. Common instructions had to be newly authored each time given. Had a legal case occurred which might have hinged on the documenting of instructions, we would have had a difficult time showing the adequacy of instructions, prescribing, cautions given, and admonition to return if failing to progress or if seeming worse.

    We now have a multi-copy discharge instruction form which may be either hand-written or computer-generated with a three-line tear-off prescription form, templates of common prescriptions including taper schedules, templates of "pre-fabricated" instructions for common conditions, cautions re: driving, work/school release, call-back number, clinic referrals, etc. We can now explain the instructions to the patient,   give a clear copy, and obtain a signature for the instructions, and have better documentation of the process placing us in a better defensible position. Yes, we do have one more form; ---but, it does so much more for us and the patient!

    When a patient calls back with a question, or a pharmacy calls back with a question, we can look at the record of the previous visit and verify the correct information

    "Incorporation by reference" is a lawyer's term for what might be used as a quick note or reminder to oneself in the chart . . e.g., if I write "NSAID cautions" or "TYCO cautions" as given, I am then able to say "Yes, that indicates I gave those cautions and my standard set of instructions for that is: . . . " without separately listing those as I write. Thus, if I'm covering for another nurse and give some teaching during that care episode, even though discharge may not yet be planned, I can "incorporate by reference" within the note and show the appropriate teaching was done at that time.

    Be alert to your own personal mannerisms, confidence, and style when teaching patients. It's important to  seem relaxed, open, and friendly, lest the patient feel intimidated from asking questions or expressing uncertainty "because you're so busy." Mannerisms of some nurses that can "put off" the patient include: speaking unnecessarily loudly or in an unusual pitch, speaking rapidly, repeatedly asking "OK?" in a tone that implies that it should be "or else!", forgetting to restate "medical words" or concepts in everyday language, handing out brochures in a "Here, take this" manner.

    Often, patients will be asked at home "Well, what did the Doctor/Nurse say?", and find it difficult to summarize, and will then respond "Aw, they just said take these pills." There's an old but valuable joke about the very successful country preacher who was asked why his sermons were so well-remembered: "First, I tell them what I'm going to tell them; then, I tell them what I plan to tell them; then, I tell them what I just told them!" Break this down and you find a Preamble or "get them interested in what you're going to say and why they want to know it, a main section of teaching and rechecking understanding, and a summary and restatement of what they want to know and whey they want to know it-remember it-and follow through on it! And, even, "I know that you're tired and want to go home to bed and rest, which is goood!, but of course in the morning when you reread this again, you'll be able to remember clearly all the things you'll need and want to do get better quickly! Or, even, "Now, when the family asks 'what did the hospital say', you will be able to say "RICE - Rest, Ice, Compression, Elevation; use the crutches to prevent reinjury; Ibuprofen to ease pain; and follow up with the sports doctor."

    The trick to not having discharge teaching take up a lot of time at discharge is (unless new issues are discovered), to teach throughout the entire visit. When the IV is started or checked, when PO fluids are offered, giving a urinal for when he will need to pee, etc., are all "teachable moments" in teaching rehydration, I/O, fever control, etc.; you may well prevent a future visit for the same problem, not just in this patient but also his family!

    In short, I believe these elements are essential:

ball_red.gifit can be shown that the patient (and caregivers) was told:
ball_red.gifin plain non-jargon wording
(with consideration of language and reading level),
ball_red.gifwho the doctor was,
ball_red.gifwhat the problem was thought to be,
ball_red.gifwhy a definitive diagnosis can't be made, if applicable,
ball_red.gifwhat is to be done by the patient to help himself get well
(or back to baseline/as comfortable as possible considering the circumstances),
ball_red.gifwhat the patient should not do and why,
ball_red.gifwhat precautions the patient's contacts should take.
ball_red.gifcommon additional effects or adverse effects of the medicine or plan,
ball_red.gifwhat to do if any of these should happen,
ball_red.gifwhat to do if he fails to improve or worsens,
ball_red.gifwith whom and when he is to follow up
ball_red.gifnumber to call or where to go if anything wrong
(or is later confused about instructions or is unsure if worsening),
ball_red.gifcautions re medicines, e.g., hazards of driving and risky tasks,
ball_red.giflegal notifications e.g. state DMV, notifiable communicable disorders, etc.

   This may seem an imposing list, but looked at logically and carefully presented to the patient and his family need not be difficult or arduous but is giving him the toolkit he needs to do the job of taking care of himself. And, is eminently defensible in court. You may do such a fine job of teaching that the patient and his family may never return for the same problem again, except to obtain some medicine that is only Rx. Ask yourself mentally, as you teach, "What would I need to know if I were he, knew nothing at all about the problem, and am a bit scared and/or under pressure from the family?"

    Discharge Instructions benefit the patient and his caregivers, allow you to give input to the process, and can be the best friend that you and your lawyer can have.

"Discharge Instructions -- Don't Just Show Them The Door!" [http://ENW.org/Discharge.htm]
is a webarticle presented by:
Emergency Nursing World ! [http://ENW.org]
Tom Trimble, RN [[email protected]]



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