September 14, 2008, 10:19 pm

Send Them Off in a Letter to Yourself

Can you believe this?

I don’t know about you, but some of my favorite moments in nursing school were spent in “Circle Time”!


This looks like a kindergarten class listening to teacher read a book!

What, they only had one piece of paper to go around? I realize this was before the advent of technology, but surely the Gutenberg press had been invented by then!


Discharge instructions.

One of the most important duties I have in the ER is educating my patients on what is happening to them, what they need to do after discharge and when/where to follow up.

It’s disturbing to learn they understand very little of it.

It’s even worse to learn that they don’t know that they don’t know.

Check out this story from Reuters.


I had a hard time believing that so many people have so little comprehension of what they are told.

Until I started wondering why.


Of course they aren’t going to remember much.

1. They are under stress – anyone who comes into the ER, as a patient or a family member, comes in with some amount of anxiety. The ability to retain information is inversely proportional to the amount of anxiety experienced (The Law of Diminishing Retention. I just made it up.)

And then,

2. They are in pain – isn’t that the reason most people show up at the ER? Something hurts. How much information can be retained when you’re in pain?

But wait…

3. We treat the pain – usually with a narcotic. Now the anxiety (and, hopefully, pain!) is gone/diminished but the patient is groggy. How much do you remember under the influence? Of anything?

Now add to the equation the reality that…

4. Most people don’t have a clue about how their bodies work – really, they don’t. Take the average person off the street with no medical background and ask them to explain what cholelithiasis is. Or viral gastroenteritis. Or cellulitis. Now take a person who is (a) under stress, (b) uncomfortable and (c) narcotized and tell them all about what is wrong with them, anatomically, physiologically….


See where I’m going with this?

And then, finally…

5. They want to get out of the ER – take all of the above, add a wait time (some facilities are worse than others), add the time it takes to get the labs and diagnostic results back, give the doctor some time to explain those results and then give the nurse time to type up the instructions and explain them to the patient.

The patient who just wants to leave.

By then, I’m sure we don’t have their undivided attention.


But…isn’t that why we give written instructions to go?

Well, yeah, but do the patients really read them? My guess is no.

So, when I do patient education (aka discharge instructions), I do the following:

1. I educate as I go. I don’t wait to bombard the patient at the end. If the patient is sedated, I can talk to family members.

2. Keep is simple. I do a quick overview of the problem, what symptoms to look for, what to expect from the medications, and who to follow up with and when.

3. I highlight parts of the instructions that the patient needs to know right then (see #2).

4. I tell the patient and the family members that it is extremely important that the discharge instructions are read in full, not necessarily right when they get home, but within a few hours.


Those written discharge instructions cover all bases in terms of what the patient needs to know, what they need to do, when they need to do it and why they need to do it. We use a very thorough system and I add information specific to the patient.

I have a suspicion that the inability to articulate what is happening or when to follow up has a lot to do with patients not referring to their written instructions – doesn’t seem like a single patient in the above linked study referred to any discharge papers when interviewed.

The patient needs to take responsibility for their own health education once they leave the ER and keep those discharge papers.

Or maybe they should take Steely Dan’s advice and…

Send them off in a letter to themselves!


  • Healthcare Today

    September 15, 2008 at 10:03 am

    Send Them Off in a Letter to Yourself // Emergiblog…

    One of the most important duties I have in the ER is educating my patients on what is happening to them, what they need to do after discharge and when/where to follow up.

    It’s disturbing to learn they understand very little of it….

  • 10MG-IV

    September 18, 2008 at 2:41 pm

    ahhh AHH I waste more time with discharge instructions. Oh did I say WASTE time. Yes in deeedy. If I have the opportunity to give discharge instructions to anyone but the stressed drunk on morphine, freaked out patient I will do so…Drats, HIPPA. Can’t do that. I have written who to see for suture removal, what to look for re; Infection in 28 point font for the “visually challenged”. I cannot be sure some even know how to read. I suppose we will be doing an IQ test before instructions are given. It is so sad to give instructions on basic rotate Acetaminophen with Ibuprofen to young parents and they say
    “what do you mean”? Am I responsible for the lack of brain cells of those who seek medical care? Important Yes. Frustrating Definitely

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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