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The Dictated Synopsis Is A Lesson In Systemic Chaos

When a patient leaves the hospital, the physician dictates a synopsis of the hospital stay. This process is lesson in systemic chaos. For hospitalist medicine, other than direct physician to physician discussion on the day the patient leaves, this synopsis is the most important tool available to relay the events of the hospital stay to […]

When a patient leaves the hospital, the physician dictates a synopsis of the hospital stay. This process is lesson in systemic chaos. For hospitalist medicine, other than direct physician to physician discussion on the day the patient leaves, this synopsis is the most important tool available to relay the events of the hospital stay to the outpatient primary care physician and other subspecialists on the case. It lets future doctors know immediately about your patient’s hair restoration treatment plan. It lets the primary care doctor know about the causes of hyponatremia in their patient. And it lets the cardiologist know about the end of life ethical issues you had to deal with in their patient.

Unfortunately, this dictated synopsis is often a pile of garbage. What you get is highly dependent on the person who does it. There is no systemic standard that prevents a voltage drop of information after the patient leaves the hospital. Most physicians receive very little medical school education on how to dictate well. It’s trial by fire. There are templates out there on how to do it. But mostly you learn by repetition and experience.

As a medical student, I remember spending almost two hours one day dictating a synopsis of the hospital stay for the resident. I look back in horror at the day and wonder if anyone ever read it. As an intern in residency, you start out worrying about getting everything into the synopsis and hopefully by the time you are done with residency, you’ve become brief and succinct. For some people, however, that concept never sticks. For others, they take it to the extreme. Today, when a patient of mine leaves the hospital, I do my dictations immediately one hundred percent of the time. They take me about five minutes to complete from start to finish, a far cry from my days in training.

A hospital record, even if you are only admitted for one or two days can be twenty, thirty, forty pages long or more with electronic documentation from all the relevant hospital professionals. Everyone has their own documentation in the chart from the nurses and respiratory therapists to the physical therapists, the emergency room physicians and the hospitalists.

Never would I consider going through the electronic medical record page by page to decipher a hospital admission. The dictated synopsis is intended to give the reader an important overview of the hospital stay and any pertinent events. It should be the most important documentation in the chart.

Unfortunately, there is little standardization to this process across this country. It’s highly stylized and based on the whims and feelings of the man or woman behind the telephone. What do I think are the important aspects of a hospital synopsis?

1. Include the main diagnoses during the hospital stay.
2. Include a description of the surgeries and procedures during the stay.
3. Include relevant radiology and blood work results.
4. Include a list of the consultants and their subspecialty involvement.
5. Include a brief (that’s key) synopsis of the complicating conditions and hospital events.
6. Include an accurate list of the medications, including as needed medications.
7. Include a list of pending labs or studies and recommendations for further outpatient studies or labs.
8. Strive for one page or less.

In the last year or so we have been asked by our hospital transcription service to also dictate the patient’s condition in our hospital synopsis. I’ve often wondered why. Well, it seems like the Joint Commission has mandated that six components be present on the synopsis for an acute to a subacute care facility transfer. What are the six mandated Joint Commission components?

1. Reason for hospitalization
2. Significant findings
3. Procedures and treatments provided
4. Patient’s condition when leaving the hospital
5. Patient and family instructions (as appropriate)
6. Attending physician’s signature

Interesting. I never knew one could regulate a dictation. It’s hard to imagine how one could define each component. Is there a multiple choice we can click on? It all seems so silly. As for rule #4. Do they mean stable vs unstable? Are we supposed to document how badly they smell? Or that they look especially ugly today. Or perhaps the Joint Commission wants to know how financially secure they are. Perhaps they mean IQ status. Maybe they want us to document how good a father the patient is. It just seems so confusing.

Here are the real problems with the hospital synopsis process.

1. Failure to dictate in a timely manner. This is most commonly a problem with subspecialty services who take weeks upon weeks to dictate their synopsis while the hospitalist has cycled the patient through three times since their sentinel subspecialist admission.
2. Failure to include any relevant information. When a physician assistant on the orthopaedic service dictates a hospital synopsis on an 85 year old who spent 12 days in the hospital with a heart attack, acute renal failure and two cardiac resuscitations and dictates nothing more than the procedure name and random thoughts of the day, you know that no thought was put into the process. But then again, nobody gets paid less for a poor job, so why bother putting any effort into it at all?
3. Using English as your second language. If your transcriptionist can’t understand you, you have a problem. Speak slowly so you don’t get back a dictated synopsis filled with medical transcription errors.
4. Dictations that are way too long. This is a synopsis of the hospital stay, not a minute by minute, hour by hour, day by day account. If you are too wordy in your dictations you need to know that everyone hates you. Nobody reads them except you. Nobody thinks they are a masterpiece except you. A synopsis is meant to be brief. Make it brief. Whenever I admit someone, I pull up old records. What are the only things I look at on the previous synopsis? Diagnoses and medications. Everything else is noise. Plus, it’s expensive to pay someone to transcribe all that nonsense. If someone really wants to get to the fine details, they can pull up the EMR and do a deeper search.
5. Failure to carbon copy the synopsis to the primary care physician and other subspecialists taking care of the patient. If they don’t get your records, why bother with the synopsis at all?

With that said, a short synopsis is no problem at all if it includes all the relevant hospital information. While signing off my electronic records the other day, I came across this synopsis, which I consider my shortest hospital synopsis ever:

FINAL DIAGNOSIS:
1. Drug overdose, Benadryl.
2. Suicidal depression.

LABORATORIES:
Labs fine.

Thirty-two year old suicidal female took a bunch of Benadryl and was EPCd. No relevant issues. Safe to leave with no medications.

Now that’s how you dictate the shortest hospital discharge summary ever.

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