Discharge Letter

Introduction

There are numerous times when I asked patients on their discharged medications from wards, they seem to have little ideas.

• Some of them are even confused if they should continue with the old medications or only the medications on discharged prescription.
• They may also not know why new medications are being started.

Hence, bedside dispensing at wards is an opportunity for pharmacists to educate the patients on the newly started medication or any medication dose changes.

Things to Write

Often, discharge letter is the only communication that the primary care team receives information about the time spent in hospital by a patient. I would like to share a very interesting section of Surviving Prescribing A Practical Guide written for practicing prescribers.

Discharge letters following medication review

Questions to ask and things to do:

• Have you included details of the medication changes made during the admission? If the GP is to start ... and to stop... never assume that someone else knows when to stop a medication.
• If medications have been stopped, include follow-up or monitoring required in the discharge letter.
• Be realistic with GP follow up. Have you given enough information? e.g. GP to review furosemide... for what reasons? Swollen ankles, wet cough, low BP, AKI, patient adherence, etc. What is the target you were aiming for? Do you want it to be weaned off or increased to maximum tolerated dose?
• Be realistic with the timeframe. Will the GP take bloods in 2 days and review if you put it in the letter? Will it even be seen in 2 days? Have you told the patient or in urgent cases rung the GP and arranged this follow-up?
• Did the patient tell you something about their medication that the GP or community team need to know i.e. "My house is full of medicines and I get confused', 'I can't open those eye drops my pharmacy send'

The Importance

If changes are not well documented, the prescriber will often revert to the original dose assuming it was an error, undoing all your good work.

Conversely, patients where only the "key medication for this admission" were listed may have all their regular medications stopped as the GP labours under the false impression that 'the hospital must have reviewed and stopped them'.