eligible providers and hospitals Eligible hospitals must meet certain required objectives each year to receive a financial incentive and avoid a payment adjustment Well-designed discharge instructions with the information discussed below help hospitals reach the threshold for the incentive by fulfilling several objectives, including maintaining an active and updated medication list and providing discharged patients an electronic copy of their discharge instructions Legal Considerations Discharge instructions that are well designed highlight when a patient should return for care, review potential complications associated with the patient’s diagnosis, and give clear instructions for treatments These instructions can also serve as an important protection for the emergency medicine practitioner, providing documentation that may be important when an adverse event occurs or a complaint is raised A copy of the instructions provided to the patient should be maintained in the medical record GENERAL PRINCIPLES OF DISCHARGE INSTRUCTIONS Organization Instructions should be organized without a large amount of extra material that can distract from the critical information, and should be written in clear, short sentences rather than paragraphs A simplified form leads to increased patient satisfaction Information should be presented with the most important items first Separate headers with diagnosis-specific instructions enhance patient recall and understanding (Table 133.1 ) DISCHARGE INSTRUCTION FORMATS The content of discharge instructions and the process by which that content is relayed to its intended audience varies widely from facility to facility The format of the instructions can be verbal and/or written or may include multimedia technology Pictures or diagrams and other visual aids may be added Different formats have inherent strengths and weaknesses Verbal Instructions Studies of discharge after hospitalization have shown that patients prefer verbal instructions from their care provider prior to discharge Patients like to have a final interaction with their care provider to clarify ongoing treatment plans and to have a chance to ask remaining questions Verbal instructions may help to overcome literacy barriers to comprehension of written instructions However, verbal instructions alone are not adequate because they rely on variable communication skills of providers Verbal instructions alone also not provide any lasting documentation for the patient to reference Written Instructions Written materials may improve recall of discharge information A written record of the discharge instructions not only helps the patient, but also can provide valuable information to follow-up practitioners as a reference for diagnoses, care received, and changes in medications To standardize the information provided to patients/families, many centers have transitioned to preformatted instructions that have the benefit of being easily legible and may be more time efficient However, information needs to be pediatric specific and individualized Ideally, written instructions should have diagnosis-specific information structured under separate headings for each diagnosis Providers can highlight the most critical information Written instructions without verbal reinforcement are not adequate as they not give patients and families the chance to ask clarifying questions There is also a risk of discrepancy between reading comprehension level of the patient/family and the level of the instructions (see below) If the instructions are not written in the native language of the family, they will not be well understood Caution should be used to avoid including superfluous information that can distract from the crucial information There is no consensus on the optimal person to provide discharge instructions to families Patients surveyed when leaving the inpatient units of a hospital prefer their physician to review discharge instructions Ideally, one of the main care providers (MD, nurse practitioner, bedside nurse, etc.) should review instructions with the patient and provide the option of further clarification by his or her practitioner if necessary TABLE 133.1 GENERAL PRINCIPALS OF DISCHARGE INSTRUCTIONS Heading Information to include Patient identifier Patient name, date of visit ED information Discharge diagnosis Phone number of ED, practitioner name Separate header for each diagnosis Under each diagnosis Expected course Potential complications Indications for when to return Follow-up Include name, phone number, and date/time frame to see each physician, including subspecialist referrals Medications and Full prescription information, including lay other treatments instructions, on all new medications and treatments Any changes to home medications Patient/guardian Signature, relationship to patient, date and time of signature signature Witness signature (from nurse, MD, etc.) Also consider List of any procedures performed Multimedia Technology New multimedia technology offers exciting options to further enhance comprehension and retention of discharge instructions Examples include short videos describing ongoing outpatient care of common medical problems and applications that help patients track medication administration at home Hospitals can also develop website links with additional material for family reference Video instruction can help to standardize the information provided to families concerning common medical conditions, and have been shown to improve parental comprehension about the diagnosis, treatment, and when to seek further care Multimedia instruction also offers other advantages over traditional instruction, including the capability for asynchronous learning, customizable interactive content based on the needs of the patient and family, multimedia presentation to overcome literacy or language barriers, and optimization of content and presentation based on feedback using web diagnostics Other approaches, such as text messaging patients and families after ED discharge, have been associated with increased compliance with medications, and follow-up Adolescent patients may even prefer receiving discharge instructions by email or text along with printed instructions Combination Method: The Preferred Method Optimal discharge instructions combine written and verbal instructions and include pictures when relevant Including pictures as visual cues can help to improve recall Drawing pictures demonstrating the correct dosing of pediatric suspension medications may be particularly important The addition of verbal reinforcement, especially in the patient/guardian’s preferred language, may further solidify understanding of the information, while at the same time satisfying the family’s desire to have a final interaction with their care provider The provision of discharge instructions needs to be a two-way conversation, allowing the family to ask questions, and engaging them with methods such as Ask Me or TeachBack that enhance and assess their understanding OBSTACLES TO COMPREHENSION AND RETENTION OF DISCHARGE INSTRUCTIONS There are several obstacles to effective discharge instruction Up to half of patients receiving discharge instructions were not aware they had, in fact, received them Patients/parents may not even read the discharge instructions provided Often the medical provider does not review all key components of discharge instructions Even after review with a medical provider, there is variable retention of that material, and many families leaving the ED are unable to fully recall discharge information Engel et al evaluated patient understanding of discharge instructions across five domains: diagnosis, medications, home care, follow-up, and return instructions Two-thirds of discharged patients showed minimal or no understanding in at least one of the domains evaluated, with a deficit of ... benefit of being easily legible and may be more time efficient However, information needs to be pediatric specific and individualized Ideally, written instructions should have diagnosis-specific... as visual cues can help to improve recall Drawing pictures demonstrating the correct dosing of pediatric suspension medications may be particularly important The addition of verbal reinforcement,