How to write good discharge instructions

Discharge instructions are often provided as an after-thought. You’ve gone through a complex diagnostic process, interpreted various tests and imaging and initiated life saving treatment. After several high-fives, now it’s time for the patient to go home. Your job is done. Throw some pre-printed instructions at the patient, they’re on their way, and you’re on to your next patient.

But think about what the discharge instructions represent. Your patient probably only spent a few hours with you. They will be spending days with whatever information you give them to take home. This is continuation of therapy. This information is vital for the patient. This frames their ultimate understanding of what happened in the ER and what needs to happen next.

So let’s learn to do it properly. Watch the following video on how to write good discharge instructions and then bring a set of instructions you (or your attending) wrote to class. Let’s see how you did.

Humor: Heroin + Tylenol PM = Cheese

Take a break from studying and enjoy yourself with this toxicology-related comedy bit from Kumail Nanjiani. I believe he does use some foul language intermittently, so you may want to listen when delicate ears are not nearby.

M2 Applied Physical Diagnosis Orientation

Thanks to those of you who volunteered to help mentor the new M2’s learn history and physical taking skills. There is an orientation that goes along with being a faculty member in this course, and here is most of that material.


Salter Harris Fractures

This is the first in a series of videos on musculoskeletal injuries in children by Dr. Casey and me. Enjoy!

And then here are the answers.

How to rock your ER rotation

Hello M4’s, at this point in the year, most of you are taking away “audition” rotations. The goal here is to make a good impression, such that when your application comes across the residency selection committee’s desk, they remember you fondly.

You want to do well here. So how can you do that?

  • Be professional: don’t be late, be respectful. There’s a lot of emphasis on punctuality in EM – the last thing you want to do after a tiring shift is have your replacement show up late. So, show up 10 minutes early and get the lay of the land.
  • Respect the nurses: not only have they been doing this longer than you, they know more than you. Get them on your side. I suggest you take the time to learn their names… and use their names. Keep them informed of the plan. Help them out. If a patient needs a pillow, you get it. Put a patient on a bed pan.
  • Respect the patients: same applies here. Ask their names (Mr. and Mrs. So-and-so unless they insist you use their first names) and give them yours. And most importantly keep them informed of what’s going on. Rather than getting the patient on your side, you want to get on the side of the patients.
  • Ask questions: Don’t make up questions to seem inquisitive. Instead, make an effort to find out the answer first. With Up-To-Date, Smart Phone apps, websites (CDEM) you have a lot of information at your fingertips already. If you still can’t find the answer, now ask intelligent, informed questions.
  • Make decisions: this is the time where you get to flex your decision making muscles. So don’t wait for the attending to spoon feed you the plan – get all your information, take some time to synthesize it, and then make an educated guess at a plan. You’re not going to be right every time, but it’s better to commit yourself to creating a plan and show you’ve put some thought into this than to passively accept what’s given to you.
  • Have a DDx: have this ready before you present to the resident or attending. You don’t want to be stumbling guessing when asked “what could kill this patient presenting with X?” Think this out ahead of time.
  • Do the stuff you’re supposed to do: finish your charts, complete any shift cards, go to all lectures, complete all assignments, and look up whatever anyone asks you to look up. Check on all results. Don’t leave stuff half done so you can leave your shift the minute it ends. Most of your attendings and residents will be staying late to get their work done… if they are, if you have stuff left undone, maybe you should, too. Along these lines, don’t pick up a complicated patient 10 minutes before you’re supposed to leave – you won’t be able to finish. You’ll be there for hours.
  • Set expectations early: if you’re going to be asking an attending for a letter of recommendation, ask them at the beginning of the shift. “Dr. X, I’d like to get a great letter of recommendation from my time here. I was hoping you could help me excel here. I’m open to any feedback, positive or constructive.” Now Dr. X will be paying attention to you, and looking for ways to help you. If you want till the end, Dr. X likely won’t have paid 2¢ of thought to you and will make up generic advice in the heat of the moment. If you want to learn something, bring that up at the beginning of the shift. “Dr. Y, I’ve been having trouble presenting concisely. I’d like to work on that today. I’d appreciate any feedback that can help me do that.
  • Enjoy it: I know I made it sound pretty tough, but if you are considering this as a career, it should also be fun. It is fun! Sure there will be good days and bad days, but on average you should be enjoying yourself.

I’ll add more here if I think of it.

Early Goal Directed Therapy in Sepsis

This short video explains how to recognize and take care of the septic patient in the Emergency Room. The important things to remember are that:

  • Start therapy early – preventing death in the ICU depends on early and aggressive therapy in the Emergency Room.
  • Trend your lactate! That’s a good marker for hypoperfusion
  • Antibiotics within the first hour. Actually as soon as you recognize sepsis

You’ll also hear a dog longing for her owner in the background. I hope that’s not too distracting. Also if you want the PDF of this drawing (not sure why you would), you can get it right here.

EM4 Rotation Objectives

Here at Rush we have a required clerkship in Emergency Medicine. As faculty here, you are not only doctors but teachers. So we should know what the students are here to learn – what the students are expecting us to teach them.

These objectives were taken from a national consensus created by clerkship directors from across the country. They have also been matched with Rush Medical College’s terminal objectives (things we want our students to be able to do before graduating).

They are grouped into the 6 “competencies” similar to those on which residents are evaluated. These are:

  1. Patient Care
  2. Medical Knowledge
  3. Self-Directed Learning
  4. Interpersonal and Communication Skills
  5. Professionalism
  6. Putting Care into a Practical Context

Below I’ve listed what each of these mean in greater details and some examples of how we can teach these to our students.

Please feel free to comment. Are there better ways to teach these? Do you have any special effective teaching tricks? I’m all ears.

Patient Care

Under direct faculty supervision, students should be given primary responsibility for patient care (of noncritical patients) and begin to act independently during the fourth-year EM rotation. Primary responsibility for patient care will help foster the students’ ability to think critically, assess their knowledge and skills, and allow them to make clinical decisions affecting patient care.

Specific Learning Objectives

  1. Obtain an accurate problem-focused history and physical examination.
  2. Recognize immediate life-threatening conditions.
  3. Patient management skills:
    1. Develop an evaluation and treatment plan;
    2. Monitor the response to therapeutic interventions;
    3. Develop appropriate disposition and follow-up plans.
  4. Health promotion:
    1. Educate patients on safety and provide anticipatory guidance as necessary related to the patient’s chief complaint;
    2. Educate patients to ensure comprehension of discharge plan.

Was their history and physical accurate? Were they able to recognize that the vital signs were grossly abnormal? Can they make and follow-through with a plan? Are they checking on the CT results? Are they finding out why that urine was never done? For patients being discharged, they should be able to educate patients on how to be safe - most easily through the discharge instructions.

Medical Knowledge

Students should develop a differential diagnosis that is prioritized on potential life-threatening conditions and likelihood of disease. Students should demonstrate knowledge (or understanding) of basic diagnostic modalities and interpretation of results. Most importantly, students should cultivate an appreciation of risk stratification and pretest probabilities for selected conditions.

Specific Learning Objectives

  1. Develop a differential diagnosis when evaluating an undifferentiated patient:
    1. Prioritize likelihood of diagnoses based on patient presentation and acuity;
    2. List the worst-case diagnoses.
  2. Create a diagnostic plan based on differential diagnoses.
  3. Develop a management plan for the patient with both an undifferentiated complaint and a specific disease process.

Can the student come up with an appropriate differential diagnosis which includes life threats and probable causes? Does their testing make sense?

Self-Directed Learning and Lifelong Improvement

Practice-based learning can be demonstrated through systematically evaluating patient care and population features; teaching other students and health care professionals; and applying knowledge gained from a systematic evaluation of the medical literature, including study design and statistical methodology.

Specific Learning Objectives

    1. Effectively use available information technology, including medical record retrieval systems and other educational resources, to optimize patient care and improve their knowledge base.

Can the student find the answers to questions they don't know by themselves? Were they able to look up how good is ultrasound for appendicitis?

Interpersonal and Communication Skills

Students are an important element of the health care team, and effective communication with patients and other health care providers is essential for patient care. Students must demonstrate interpersonal and communication skills that result in effective information exchange and interaction with patients, family members, and health care providers.

Specific Learning Objectives

  1. Humanistic qualities
    1. Effectively communicate with patients, family members, and other members of the health care team
    2. Demonstrate a compassionate and nonjudgmental approach when caring for patients.
  2. Presentation skills:
    1. Present cases in a complete, concise, and organized fashion;
    2. Effectively communicate with consultants and admitting services.
  3. Documentation: provide accurate and organized documentation in the medical record when appropriate.

Did they establish a relationship with their patients and their families? Are their presentations clear and concise? Can they coherently call a consult or and admit up to the floor? Are their charts done?


Professionalism should be viewed as an academic virtue, not just an expected set of behaviors. Students should learn to reflect on their professionalism during clinical rotations and learn from faculty role models.

Specific Learning Objectives

  1. Work ethic
    1. Be conscientious, on time, and responsible;
    2. Exhibit honesty and integrity in patient care.
  2. Practice ethical decision-making.
  3. Professional behavior:
    1. Exercise accountability;
    2. Maintain a professional appearance
    3. Be sensitive to cultural issues (age, sex, culture, disability, etc.);
    4. Work in a collegial manner with other members of the health care team.

Were they on time? Honest? Professionally dressed? Basically, did they act like we expect a doctor to act?

Putting Care in a Practical Context

Called Systems-based practice in the resident lingo, this competency extends beyond the individual patient’s bedside to include an understanding of how EM relates to other practitioners, patients, and society at large, while considering the cost of health care and the allocation of health care resources. Understanding the ‘‘system’’ involves learning ways to advocate for patient care and assist patients in dealing with system complexities (such as assuring appropriate follow-up) and how to partner with health care providers to assess, coordinate, and improve patient care.

Specific Learning Objectives

    1. Recognize when patients should be appropriately referred to the emergency department (ED).
    2. Recognize the importance of arranging appropriate follow-up plans for patients being discharged from the ED.
    3. Recognize the role of EM in the community, including access to care and its impact on patient care.
    4. Understand the indications, cost, risks, and evidence behind commonly performed ED diagnostic studies.

I'll admit this one is tougher to measure. Some things I'd look for is inappropriate use of testing or resources? Do they request too many consults? Too many MRI's? Do they make sure the patient has follow-up, especially in those that need to be seen immediately? And that may mean coming back to the ER.

I hope this helps clarify our objectives a little bit. If you have any questions, please feel free to comment.

Altered Mental Status

Here’s a video on Altered Mental Status. It runs nearly 20 minutes (should have broken it up into two videos – sorry about the length). The key here is in the differential diagnosis, as usual:


If my chicken scratch is of any worth to you, here’s a PDF.