Discharge Instructions: What Do Patients Remember?

Brent Hill, RN MS PhD, Qing Zeng-Treitler, PhD

University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, Utah 84108

Introduction When a patient leaves the hospital, he is provided with instructions for his post-hospitalization care, follow-up appointments and tests, and other patient education information. However, patients have a difficult time understanding their discharge instructions.[1-3] The objective of this study is to understand the types of information patients remember and don’t remember in their discharge instructions. This information will be used to inform informatics interventions to improve patient comprehension, recall and adherence to discharge instructions. This study builds on prior research in which illustrated versus non-illustrated discharge instructions were tested with 144 patients to evaluate their recall of and satisfaction with their discharge instructions.[4, 5] The first 50 discharge instructions were analyzed for this study.

Methods Patients on a Cardiovascular Medical Unit at the University of Utah Hospital were asked to remember the content of their discharge instructions after their final discharge teaching was completed by their nurse and they were discharged to go home. Patients received disease specific discharge instructions for their diagnosis or procedure. Study participants were asked to review their instructions for up to 15 minutes then prompted by the study nurse to recall their instructions as the nurse asked them to state all of the information they could remember as the nurse read the title of each discharge instruction section such as diagnosis, signs/symptoms to be vigilant for, wound care, activity restrictions… until each section was reviewed.

Three levels of analysis were conducted for this study. The first level of analysis consisted of reviewing discharge instructions by section. The second level of analysis consisted of reviewing discharge instructions in detail by individual instruction. The third level of analysis evaluated the information based on the immediacy of the need for the instruction. Patient’s discharge instructions were based on their diagnosis or procedure so instructions varied. Content analysis was completed by quantification of instructions by remembered or did not remember and a ratio was calculated based on the percentage of participants who received that instruction who did or did not remember the instruction.

Results The results for the first level of analysis revealed the percentages patients did and did not remember in the following sections of discharge instructions: Diagnosis, General Care, Wound Care, Activity Level, Restrictions, Diet, Other (Table 1). The second level of analysis presents selected discharge instructions and the percent of patients that did and did not remember the instruction (Table 2). The third level of analysis examined the immediacy of instructions versus general health education. A cardiologist independently evaluated the discharge instructions for immediacy of information by highlighting information that he deemed necessary for the patient’s first week post-hospitalization. Analysis of the instructions revealed that 27% of the discharge instructions were necessary for 1 week post-hospitalization and 73% of the discharge instructions consisted of general health education.

Discussion It is necessary to understand how patients retain information from discharge instructions in order to prioritize the content and delivery of discharge instructions. Through the understanding of recall of discharge instructions, improvements can be made with the timing and content of discharge information to maximize their impact. This information will be used to inform informatics interventions that will tailor and deliver information for the patient, which will support the patient during this transition of care.

Table 1. Percent of Discharge Instructions by Section.

Primary
Diagnosis / General Care / Wound Care / Activity / Restrictions / Diet / Other
Remembered / 78% / 17% / 26% / 22% / 39% / 24% / 4%
Did Not Remember / 22% / 83% / 74% / 78% / 61% / 76% / 96%

Table 2. Percent of Discharge Instructions by Instruction.

Remembered / Did Not Remember
Having signs of a stroke including weakness or numbness in your face or limbs-expecially on one side of the body-confusion, loss of balance, trouble speaking or seeing. / 9% / 91%
Look at your wound every day for signs of infection. / 26% / 74%
If you start to bleed from an incision, apply pressure for 15 minutes. Do not let go. Check after 15 minutes. If you are still bleeding, re-apply pressure and call 911. / 34% / 66%
Do not bear down or push hard to have a bowel movement or strain while working. / 6% / 94%

1. Engel KG, Buckley BA, Forth VE, McCarthy DM, Ellison EP, Schmidt MJ, Adams JG: Patient Understanding of Emergency Department Discharge Instructions: Where Are Knowledge Deficits Greatest? Academic Emergency Medicine 2012, 19(9).

2. Chugh A, Williams MV, Grigsby J, Coleman EA: Better Transitions: Improving Comprehension of Discharge Instructions. Frontiers of Health Services Management 2009, 25(3):11-32.

3. Helping Patients Understand Their Medical Treatment [http://www.kaiserhealthnews.org/stories/2011/march/01/health-literacy-understanding-medical-treatment.aspx]

4. Bui D, Nakamura C, Bray BE, Zeng-Treitler Q: Automated illustration of patients instructions. AMIA Annual Symposium Proceedings / AMIA Symposium AMIA Symposium 2012, 2012:1158-1167.

5. Zeng-Treitler Q, Kim H, Hunter M: Improving patient comprehension and recall of discharge instructions by supplementing free texts with pictographs. AMIA Annual Symposium Proceedings / AMIA Symposium AMIA Symposium 2008:849-853.