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Discharge

Discharge is a process that starts at admission, not an event on the last morning. What has to be true before they leave, and where the errors actually live.

Discharge readiness

Six things that have to be true, a patient, and the question of which are not yet. Tick what is already true, commit, and find the blockers. The pediatric version sits beside the adult one so the difference is visible.

Pediatric discharge

The bronchiolitis discharge

8-month-old, bronchiolitis day 6. Off oxygen since 06:00 (now 14:00). Took 90 mL, 120 mL and 60 mL of usual 150 mL bottles today. Slept two hours on room air with saturations 94 to 97 percent. Mother confident with suction. Lives 90 minutes away; father works nights; no car during the day.

Tick every criterion that is already true, then commit. The ones you leave unticked are your blockers.

Adult discharge

The COPD discharge

72-year-old, day 4 of an exacerbation of COPD. Off oxygen 24 hours with saturations 89 to 91 percent on air (baseline 90 percent). Walked the corridor with physio with saturations holding. Steroid course written to finish in 3 days. Lives alone, second-floor flat, daughter visits weekly. Inhaler technique not yet reviewed. Sputum culture pending.

Tick every criterion that is already true, then commit. The ones you leave unticked are your blockers.

Adult discharge

The heart failure discharge

68-year-old, day 5 of a heart failure admission. Weight down 4.2 kg, off intravenous diuretic 36 hours, on oral furosemide with a stable creatinine. Walks the ward without breathlessness. Lives with her husband. Discharge weight not yet written on the letter. No daily-weight plan explained. Echocardiogram result pending from yesterday. Follow-up 'with the family doctor'.

Tick every criterion that is already true, then commit. The ones you leave unticked are your blockers.

Pediatric discharge

The gastroenteritis discharge

18-month-old, gastroenteritis, moderate dehydration treated orally over 5 hours. Kept down 520 mL of oral rehydration solution, passed urine twice, heart rate 118 from 148, playing. Father has been shown the syringe technique and given the solution. Return precautions discussed. Family doctor appointment in 2 days.

Tick every criterion that is already true, then commit. The ones you leave unticked are your blockers.

10 minute read

Discharge is a process, not an event

The safe-discharge checklist: the acute issue's trajectory is proven (not just one good morning), medications are reconciled with every change explained, follow-up is booked with a purpose stated, pending results have owners, red flags are told to the patient in their own words, and the function question (stairs, meals, cognition, support) is answered honestly.

Discharge planning starts at admission: 'what has to be true for this person to leave?' is a day-one question whose answer becomes the daily rounds checklist.

Medication reconciliation is where errors live

Three lists must agree: what they took before, what they are on now, and what they leave with. Every difference is either explained in the summary or it is a mistake waiting downstream. Held medications (the enoxaparin problem) are the classic dropped thread: a hold is a decision with an expiry date and an owner.

The summary is a baton

The discharge summary is the only part of the admission the next clinician will ever read, so build it for their two minutes: diagnoses stated as facts with the evidence one clause deep ('NSTEMI, peak troponin 890, medically managed'); a hospital course in five lines that explains decisions rather than narrating days; every medication change on its own line with a reason and, for holds, a restart condition; pending results each with a named owner and a route back to the patient; and follow-up appointments each with a stated purpose, because a clinic date without a question attached is a slot, not a plan.

Teach-back closes the loop

The patient's half of discharge is a separate document in plainer words: what happened, what changed in their medications and why, which symptoms mean 'come back now' (written as symptoms they can feel, not diagnoses), and who to call first. Then close the loop: ask them to say the plan back. Teach-back is the cheapest readmission-prevention intervention in the hospital, and the first sentence a patient cannot repeat back is the sentence that was never actually communicated.

Pearls

  • The discharge blocker belongs in every morning presentation.
  • 'Follow up with GP' is not a plan; 'GP in one week to recheck potassium and restart ramipril if normal' is.
  • A held medication without a restart condition and an owner is a future adverse event.
  • If the patient cannot say the plan back, the plan does not exist outside the chart.

Connected

TopicThe discharge summaryTopicThe pending results you are handing over