■ Physician-patient:

Communicating effectively with patients to optimize their care

Documentation of discharge instructions

Type of activity: Quick activity

Activity summary

These 5 short scenarios illustrate situations in which the physician is required to document discharge instructions. The facilitation questions focus on helping learners identify the key information that should be documented.

Scenarios

Scenario 1

A 23-year-old university student has been having symptoms of depressed mood the past 3 months. The patient has had some suicidal thoughts but no specific plan. You prescribe antidepressants and arrange follow-up at your clinic in 2 weeks.

What discharge instructions would be important to communicate to the patient and document?

Scenario 2

A 40-year-old patient with chest pain and a family history of coronary artery disease wishes to leave the Emergency Department before the chest pain work-up is completed. You are concerned this chest pain may be acute coronary syndrome.

How would you document your discussion with the patient and the informed discharge? 

Scenario 3

A 54-year-old patient has a crush injury to their leg and is referred for follow-up in the orthopaedic clinic in 2 weeks. In this time, the patient is at risk of developing compartment syndrome.

What discharge instructions would be important to communicate to the patient and document? 

Scenario 4

A 32-year-old patient who is 8 weeks pregnant presents to your office with vaginal spotting and pain in her LLQ. You arrange for an urgent transvaginal ultrasound the next day. You are concerned about a possible ectopic pregnancy or threatened miscarriage.

What discharge instructions would be important to communicate to the patient and document?

Scenario 5

A 49-year-old patient has been diagnosed with a resolved episode of acute biliary colic. The patient is scheduled for surgery in the next 3 months.

What discharge instructions would be important to communicate to the patient and document?

Additional resources

CanMEDS: Communicator, Professional

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.