The Discharge Summary
A junior doctor drafts the following discharge summary for a patient leaving a respiratory ward:
Mr O'Connor was admitted with an exacerbation of COPD and improved on steroids and nebulisers. He was seen by physio and mobilised well. He was advised to continue his inhalers and to come back if he gets worse. His wife was told the follow-up would be arranged. No further follow-up was arranged. He was discharged on prednisolone 30 mg for five days and his usual medications.
The ward clerk, who has no clinical training, will upload this text to the shared record and, on the practice manager's instruction, send the same text unchanged as a letter to the patient. The patient's GP has asked for a summary that can be acted on without telephoning the hospital.
1. Identify three features of this passage that make it unsafe as a handover document, and explain the clinical risk each creates.
Read the worked answer
First, 'he was advised' and 'his wife was told' hide who advised and who was responsible for arranging follow-up, so a reader cannot tell whether the plan was completed. Second, 'come back if he gets worse' gives no measurable threshold; worse breathlessness, fever, chest pain or increased inhaler use mean different things to different readers, and a vague instruction is easily ignored. Third, 'his inhalers' and 'his usual medications' are not named with doses, and the passage both says follow-up would be arranged and that none was arranged. Clinically, these gaps risk the patient continuing an unclear drug regimen and failing to seek help at the right moment, and they leave the next clinician unable to establish what was actually agreed. The contradiction about follow-up is the most hazardous, because it makes the document unreliable as a whole.
2. Rewrite the passage in no more than 80 words so that it is unambiguous and safe, without inventing clinical information.
Read the worked answer
The original fails because each sentence omits the actor and the specific detail. A safe version names the responsible person and makes the safety-net measurable, using placeholders where the original gives no information:
Mr O'Connor was admitted with an exacerbation of COPD and improved on steroids and nebulisers. Physiotherapy reviewed him on [date]; he mobilised independently. On discharge, Dr [name] advised him to continue [inhaler name and dose] and prednisolone 30 mg daily for five days. [Name and role] will arrange [specific follow-up] by [date]. He should seek urgent review if breathlessness, chest pain or fever develops.
The placeholders are deliberate. Inventing a dose or a follow-up date would make the document look complete while remaining wrong, which is more dangerous than an obvious gap.
3. The practice manager wants to send this text unchanged as a letter to the patient. Identify the register and clarity problems this would cause.
Read the worked answer
Sent unchanged to the patient, the letter fails on both register and clarity. 'Exacerbation', 'nebulisers' and 'mobilised' are clinical shorthand, and writing about 'Mr O'Connor' in the third person to Mr O'Connor himself reads as distant or administrative. The passive 'he was advised' leaves the patient unable to tell who gave the advice or whether the promised follow-up exists, and the sentence 'no further follow-up was arranged' directly contradicts the earlier statement. The result is a letter that looks authoritative but leaves the patient unsure what to do. A patient-facing version should use 'you', active verbs, plain terms with the clinical term in brackets where useful, and one clear instruction about when and whom to contact. The clinical version and the patient version should be separately written, not copied from one another.