Discharge to Home

When you go to the ER for medical care and are discharged home, almost every ER will send you home with “discharge instructions.” In a perfect world, this would contain information that is actually relevant to the patient’s medical condition and cover what was done in the ER, the results of lab tests and imaging studies, and “return precautions” – when to come back to the ER.

In practice, nope. If you’re seen for abdominal pain, you get a sheaf of papers that is exactly the same sheaf of papers that pretty much everyone else I’ve seen with abdominal pain that day got. It reads something like this:

“You were seen today at NARH for ABDOMINAL PAIN. Your workup, which included a HISTORY AND PHYSICAL and LABORATORY TESTS and A CT SCAN, revealed that your ABDOMINAL PAIN is due to GASTRITIS. You should follow up with your PRIMARY DOCTOR in 1-2 days.”

And so on.

A few companies have tried to create stock sets of instructions for everything from “Recovering After Bariatric Surgery” to “Taking your Omeprazole.” Our company at NARH is called StayWell.

When I go to send someone home from NARH, I go hunting for some stock discharge paperwork that vaguely fits the patient’s ultimate problem. Did you come in with a cough that is probably a cold, or maybe a little bit of an asthma flare? You get “Self-Care for Colds” and “Managing Your Asthma With Inhalers.” Chest pain with a negative workup for heart disease? “Chest Pain Not From Cardiac Causes,” “What to Watch For With Chest Pain,” and “Managing Your Chest Pain At Home.”

gastritis dc

my absolute favorite.

We are all intimately familiar with these discharge instructions, because discharging someone from NARH is an odious and arduous process that was designed by a satanic IT professional who must have had a very bad colonoscopy followed by unclear discharge instructions.

When we send a patient home, we must open a new window that renders the rest of the medical record inaccessible. Before closing that locking window, we have to put in:

  • A discharge diagnosis, which about 70% of the time in the ER is something as nonspecific as “abdominal pain”
  • Any prescriptions or last-minute medications to give
  • The aforementioned StayWell instructions
  • Any follow up appointments that we tried and failed to schedule, because we are Not A Real Hospital
  • Return precautions
  • The patient’s telephone number, in case they need to be called about a lab result that won’t come back until tomorrow*
  • A check mark in a box that says “patient and family verbalized understanding.”

Completing each of these tick marks requires a NEW window to open. This is, by the way, all performed on computers bought in 1997, running Windows 95 and using a bloated electronic medical record program with enough buggy code to crash the space shuttle.

As you might imagine, it’s a slow process. It also crashes about eight times a day, on average.

*About that telephone number: if you forgot to write it down before you opened the discharge window, you are screwed and have to start all over, because the GODDAMN WINDOW PREVENTS YOU FROM ACCESSING THE PATIENT’S TELEPHONE NUMBER RECORDED ELSEWHERE.

Anyway. I’m not mad. I’m apathetic.

I recently discovered my absolute favorite Discharge Instruction. It nicely dovetails with another part of the discharge process, the return precautions. This Discharge Instruction is called “When To Use the Emergency Room.”

There is a (huge) subset of patients that come to NARH that, because of our broken system and generally awful health literacy as a society, do not take any medications at all without an emergency room doctor expressly telling them to do so. I am not criticizing these patients; it’s simply a function of just how the US healthcare and education systems fail those who have difficulty accessing it. A typical conversation with one of these people goes like this:

Me: “It sounds like your burning stomach pain after eating is from gastritis. Does this feel like your previous episodes of gastritis?”

Patient: “Yes.”

“Did the Mylanta we gave you last time fix it?”


“Did you get a prescription for the Mylanta at home?”


“Did you take the Mylanta at home before coming to the ER?”


“Why not?”


A long pause follows, after which I smile, pat the patient’s shoulder, and leave.

This particular patient subset gets – as you might guess – Mylanta, and then goes home with “When To Use The Emergency Room” as well as “Understanding Gastritis” and “Treating Your Reflux.”

I am dimly aware that “When To Use The Emergency Room” does nothing to reduce ER utilization, but it makes me feel vindictively warm inside.


the magic juice.

The other important part of discharging a patient is to provide good return precautions. These are exactly what they sound like – reasons to come back to the ER if certain things get worse. To satisfy the byzantine and confusing law known as EMTALA, we are never allowed to dissuade people from using the emergency department for stupid reasons, but we can encourage them to come back for good ones.

It’s a delicate balance. For certain conditions – abdominal pain where we didn’t get a CT scan, for instance – it’s genuinely important to tell patients “come back if you get worse or if you spike a fever.” For the aforementioned disease known as Chronic Mylanta Deficiency, being a bit more cautious is probably helpful.

What I want to write is “If this pain comes back, DO NOT come to the emergency room.  Take the Mylanta. Please. Please god, try the Mylanta first.”

This is, sadly, illegal, and we are not allowed to say this.

I worked the last two days, which covered Thanksgiving and the day after. You can imagine the number of people to whom I gave this magic medicine.

Writing this gave me gastritis. I’m going to NARH.

(to work. again.)



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