Make sure you obtain an accurate phone number for each patient you discharge and call them 2-3 days after they return home or to a rehab or nursing facility. You may want to alert your patients ahead of time that you plan to call them. The purpose of this call is to find out how they are doing, whether they are complying with the recommended therapy (if not, why?), whether they have questions, when they plan to see their doctor, and what their understanding is of their illness. If you discover problems, you are expected to bring them to the attention of your team. You may not reach every patient. Please try to contact each patient at least 3 times at different times in the day.
Within a week of discharge, call your patients to check on them. You may want to alert them ahead of time that you will be calling and make sure you have accurate contact information. There is a Discharge Patient Education Tool (DPET) available on-line that you can fill out with your patient prior to their discharge. If you have this, then you can simply refer to it during the phone call.
Please briefly address the following 4 areas:
- How patient was doing and whether they understood their condition, if not, why?
For example, find out how they are and whether the primary problem(s) are responding as expected to the treatment. You will need to know their chief complaint and final diagnoses. The chief complaint will allow you to confirm how their symptoms are doing. The diagnosis will allow you to determine whether they understood what was wrong. If you determine they didn’t understand their diagnosis, you may explain it.e.g. For a patient admitted with shortness of breath and cough, diagnosed with pneumonia, “How is your breathing? Is the cough better? Do you know what we thought caused that?”
- Describe any adherence problems you identified and what you did to help fix it.
Find out if they are taking their medicines as prescribed and/or receiving any therapy or other treatments as ordered (e.g. PT, home nursing, oxygen). Ask patient to get their medicine bottles and read them off and compare what they are taking to your discharge list. Correct any confusion and if they are missing any medicines or other therapy, find out why. Inquire about side effects.
- Describe any barriers to follow-up and what you did to help fix it.
Find out when they are scheduled to see their doctor(s) for follow up and whether they anticipate any problems making those appointments.
- Any other question that you found interesting
Inquire about any other questions related to the hospitalization or their condition.
Please provide a brief reflection on anything you learned from this or something that surprised you or even your feelings about the value of this exercise.
You are expected to admit a minimum of 16 patients during the clerkship so you should provide a record of 16 phone calls (see Sample Post-Discharge Phone Call Documentation). If some of your patients have not been discharged at the time you rotate off the service, simply note this and there will be no penalty. If you are unsuccessful in your attempts to reach a patient, simply note that as well. In order to earn an exemplary on this assignment, you must provide a general reflection on something you learned from this experience that you think might impact your future practice of medicine.