Discharge Summaries: the Bane of My Existence

After a patient is "cured" enough from their hospital illness to go home (or go to a rehab facility or wherever), they are "discharged" from the hospital. Upon discharge, a report is written by one of the doctors who cared for them summarizing their prior medical history, summarizing the events leading up to being hospitalized, what happened during the hospital stay, significant physical exam and lab findings, then how things were looking the day of discharge and what the follow-up plan is going to be for each of the problems identified in the past, present, and future. It is an odious task to write this report, as you can imagine these summaries can be rather long. They are the responsibility of the hapless intern. They are the bane of my existence.

If my regular workday runs from 6am to ~6pm, and I have to wake up at 5am to start my day, and once I get home after work I still have to take care of my ADLs like eating, bathing, picking up the mail, and whatever else I do to remain a marginally functional person, it's basically already time to go to sleep again. So it's understandable how one might fall behind in their discharge summaries. I learned the other day that if you fall behind for a few days, you get a nasty message that basically says, "You fail at life. How could you NOT have the discharge summaries done? Die. Just die now." That's in my own words, of course; the original message, generated by the medical record keeping department, was much more graphic. But seriously, it did include the phrase "48 hour suspension" as a punishment for being a few days late in completing the summaries. At first I was elated- my punishment for not completing all my work would be to have 2 days OFF to catch up?! Delightful!!! But then I found out that the "suspension" means I still have to go to work, but my name just gets put on a list that goes to my program director. It would be more accurate to call it a "shaming" than a "suspension" but whatever.

You have two choices with the discharge summaries. You can type them or "dictate" them. I hate dictating. There isn't really a nice quiet place for you to do this since as a resident you don't have an office; you do this over the phone in a busy workroom full of your colleagues, or you try to sneak off to an empty conference room so that you can dictate in peace only to be interrupted halfway through your dictation and kicked out of the room by a bunch of vascular surgery residents who say they are rounding in that conference room imminently. You call up the dictation number and record yourself saying out loud all the information that needs to go in the report, following the proper report format [including instructions for "next paragraph" or "next line" so your transcription doesn't come out as one long ugly block of text], and this recording is later transcribed by someone in the basement somewhere, and a copy goes to your electronic inbox for review and signature. This is terrible for two main reasons.

ONE: apparently my voice is unintelligible to the trolls in the basement doing the transcriptions. I say this because, (a) I've never met ANYONE who works in transcriptions, thus I suspect they hire trolls, who toil away in the basement, (b) whenever I get the transcriptions back they have all kinds of strange words written down that I know can't have possibly sounded like anything I was trying to say at the time, so I end up needing to make extensive revisions.

TWO: the dumbest, most RAHtarded things come out of my face, and when I see them transcribed in the report it is mortifying. Did I really say, "The patient is taking a night-time dose of insulin at night, which is 15 units of lantus insulin, nightly... each night. At night." ?!? Or is a troll just messing with me? Sadly, I suspect I DID say that. ::Shame::

The only solution to this problem: the shitcharge.

Given the complexity of the patients we see at University Hospital, it takes over an hour to do a really great job on writing a discharge summary. I don't have that time. Or when I do take that time, I fall behind in my summary reports and then I get in trouble. So I can battle the trolls and try to dictate the summary, which always ends badly, or I can write the fastest, shortest discharge summary that contains what I hope is all the pertinent information. If I limit myself to less than 30 minutes per brief discharge summary, it becomes a highly efficient process. And by "efficient," I mean just "shitty" because it takes me like 15 minutes to write a decent email so you can imagine what kind of quality report I can put out in 20-30 minutes. Thus, we have the shitcharge summary. It's a fairly decent summary of the main issue requiring hospitalization, but every other relatively chronic issue is just going to be listed by name, followed by "stable," or "continue outpatient management". The goal is brevity, forsaking detail.

I have to go catch up on some S/C summaries...