Timothy R. Bone

Hospital Discharge Instructions

JACKSONVILLE—Hospital discharge instructions fall under the broad spectrum of non-clinical risk management issues that represent as much as 80 percent of all medical malpractice lawsuits in the practice of medicine.

Addressing this non-clinical issue via the scientific method strives to uncover the epidemiology of the problem, identify the issue at hand, provide an “outcome goal,” and then offer a relatively simple approach to data-gathering via chart review, observations, or simple surveys, said Timothy R. Bone, president of Jacksonville-based MedMal Direct Insurance. 

“Each participant can enrich the specific approach if warranted, and can also share outcomes,” he said. “Though these reviews take some effort, they have shown over time to achieve the stated goal: mitigation of the risk that leads to medical malpractice lawsuits.” 

At issue is failure to document instructions that healthcare providers give to patients at the time of hospital discharge.

The solution is to achieve a level of performance where 100 percent of hospital charts document the discussions of all matters of clinical importance with the patient at the time of discharge, said Bone.

Bone outlined the review procedure:

1.      Gather a sample of 50 charts of patients who have recently been discharged from your hospital.

2.      Monitor each chart for the presence of documentation that the following list of items, which may be edited by the hospital staff, have been discussed with the patient at the time of discharge:

a.      What treatment was rendered to the patient during the hospital stay?

b.      What activity restrictions does the patient have and for how long?

c.       What drugs have been prescribed and how does the medication list differ from when the patient was admitted to the hospital?

d.      Where does the patient get the prescription(s) filled?

e.      With which physician will the patient follow up for treatment, when is the follow up appointment scheduled, and is the physician’s contact information listed? Does the patient understand that it is their responsibility to make the initial phone call to schedule the follow up appointment?

Actions to be taken:

1.      If all documentation is in order, notify the medical executive committee (MEC) at the next meeting.

2.      If problems exist, devise a solution in collaboration with hospital administrators, implement that solution, and re-visit the issue after six months.

3.      Make sure and report this updated information–good or bad–to the MEC.

“An added point of emphasis is that many hospitals have implemented a ‘discharge planning’ procedure for the nursing staff, which then becomes a part of the patient’s chart after the discussion with the patient,” said Bone. “Does your hospital have such a procedure?” 

Bone noted it’s important to mitigate the causes of medical malpractice at the “grass roots” level—the level of administrative protocols, systems management, and the behavior of healthcare practitioners. 

“By implementing a proper discharge planning procedure, administrators and practitioners at all levels of the practice of medicine can reduce the frequency and severity of medical malpractice lawsuits,” said Bone, “and can thus reduce the financial and emotional costs that medical malpractice allegations bring to medicine.”

Editor’s Note: This article marks the third in a risk management series with Timothy R. Bone, president of Jacksonville-based MedMal Direct Insurance. The Florida Medical News papers will address some of the most common non-clinical problems by objectively approaching each issue and its resolution via the scientific method. This process includes providing an “outcome goal” or objective, and then offering a relatively simple approach to data-gathering via chart review, observations, or simple surveys.

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