Last month I discharged a woman with a new diagnosis of heart failure. Before she left, the nurse printed her instructions. They ran to 11 pages. The part that mattered, which was to weigh herself every morning and call if she gained three pounds, was on page seven, below a paragraph about our privacy policy.
She came back four days later, short of breath, carrying the papers in a plastic bag. She had read them, she told me. She just didn’t know which parts were important.
Who the papers are for
Discharge instructions in most American hospitals are generated by the electronic health record. They are written to satisfy regulators, protect the hospital and make billing easier. Patients are, at best, the fourth audience.
Researchers have looked at this for years. A review by Dr. Ana Lucia Brennan and colleagues found that most discharge documents were written at a 10th- to 12th-grade reading level, while health literacy experts recommend sixth grade.
What would help
We don’t need new technology. We need a single page, at the top, in plain words, that tells the patient three things: what is wrong, what to do every day, and when to come back. Then we need someone to read it with them, out loud, and ask them to say it back.
That last step is called teach-back, and it takes about four minutes. In a busy emergency department, four minutes is a lot. It is still less than a return visit.
Julian Abernathy is an emergency physician in Albuquerque, N.M., and edits Second Opinion.