Writing Discharge Instructions Surgical

Checkpoint A: Pre-Draft Intake (Mandatory)

1. What procedure was performed? Default: [VERIFY — obtain from operative report]
2. Were there any complications during surgery or the hospital stay? Default: none
3. What is the patient's wound closure method (sutures, staples, adhesive strips, drains)? Default: [VERIFY]
4. Is the patient being discharged with any drains, catheters, or devices? Default: no
5. What medications are being prescribed at discharge (especially opioids, antibiotics)? Default: [VERIFY from discharge medication list]
6. What is the patient's health literacy level? Default: standard (5th-8th grade reading level target)
7. What is the patient's living situation (alone, with caregiver, skilled nursing facility)? Default: home with caregiver
8. Does the patient need home health services (wound care, PT, visiting nurse)? Default: no

Documents to Request

• Operative report summary
• Hospital course summary
• Discharge medication list with reconciliation
• Follow-up appointment details
• Home health referral (if applicable)
• Drain care instructions (if discharged with drain)
• Procedure-specific discharge instruction template (institutional)

Step 1: Discharge Summary Header

Provide the essential reference information at the top of the document:

DISCHARGE INSTRUCTIONS

Patient Name: _______________
Date of Surgery: _______________
Procedure Performed: _______________
Surgeon: _______________
Surgeon Office Phone: _______________
Follow-Up Appointment: _______________ at _______________

IF YOU HAVE AN EMERGENCY, CALL 911 OR GO TO THE NEAREST EMERGENCY ROOM.
For non-urgent questions during business hours, call: _______________
For after-hours urgent concerns, call: _______________

Step 2: Activity Restrictions

Write concrete, measurable restrictions. Avoid vague instructions like "take it easy" or "as tolerated."

General Activity Restrictions by Procedure Category

Standard activity language:

• "Walk as much as possible. Take short, frequent walks starting today. Increase distance daily."
• "Climb stairs as needed, one step at a time. Use a handrail."
• "Do not drive while taking prescription pain medication (opioids). You may drive when you are off opioids for 24 hours and can turn your body comfortably to check mirrors."
• "Do not lift anything heavier than [X] pounds for [Y] weeks."
• "No swimming, bathing in a tub, or submerging your incision in water until cleared by your surgeon (typically 2-4 weeks)."

Step 3: Wound Care Instructions

For Closed Incisions (sutures, staples, adhesive strips)

Write clear, stepwise instructions:

1. First 24-48 hours: Keep the surgical dressing clean and dry. Do not remove the dressing. It is normal to see a small amount of blood or clear fluid on the dressing.
2. After 48 hours: You may remove the outer dressing. Leave adhesive strips (Steri-Strips) in place — they will fall off on their own in 7-10 days. If they have not fallen off by your follow-up appointment, your surgeon will remove them.
3. Showering: You may shower 48 hours after surgery. Let water run over the incision gently. Do not scrub or use soap directly on the incision. Pat dry with a clean towel.
4. No submersion: Do not take a bath, swim, or use a hot tub until your surgeon says it is safe.
5. Staple/suture removal: Your surgeon will remove these at your follow-up appointment on [DATE]. Do not attempt to remove them yourself.

For Patients Discharged with Drains

1. Empty the drain every [8-12] hours and whenever the bulb is more than half full.
2. Record the amount, color, and consistency of the fluid on the log sheet provided.
3. Bring the log to your follow-up appointment.
4. Secure the drain to your clothing with the clip or safety pin provided. Do not let it hang freely.
5. It is normal for the fluid to be bloody at first and gradually become lighter (pink, then straw-colored, then clear).
6. Call the office if: Output suddenly increases, fluid turns green or brown, you develop a fever, or the drain falls out.

Step 4: Medication Instructions

Write medication instructions in plain language:

Pain Management

• "Take acetaminophen (Tylenol) 1000 mg every 6 hours around the clock for the first 3 days. You do not need to wait for pain to take it."
• "Take ibuprofen (Advil/Motrin) 400 mg every 6 hours around the clock for the first 3 days. Take it with food."
• "If you still have pain after taking the above, you may take [opioid name and dose] every [X] hours as needed for moderate to severe pain."
• "Most patients need prescription pain medication for only 3-5 days. If you are still needing it after 7 days, contact our office."

Opioid Safety Instructions

• "Do not drive, operate machinery, or make important decisions while taking this medication."
• "Do not drink alcohol while taking this medication."
• "Store this medication in a locked location away from children and others."
• "Dispose of unused medication through a drug take-back program or mix with coffee grounds/cat litter in a sealed bag and dispose in household trash."
• "Signs of opioid overdose: extreme sleepiness, slow or shallow breathing, unresponsiveness. If you see these signs, call 911."

Other Discharge Medications

For each medication, state:

• Name (brand and generic)
• Dose and frequency
• Purpose (in plain language: "to prevent blood clots," "to prevent infection")
• Duration ("take for 7 days and then stop," "take until your follow-up appointment")
• Special instructions ("take with food," "do not crush")

Medications to Resume

List home medications that were held perioperatively and the restart date:

• Anticoagulants: "Resume [medication] on [DATE]. Do NOT restart until your surgeon tells you it is safe."
• Diabetes medications: "Resume [medication] when you are eating regular meals."
• Blood pressure medications: "Resume tomorrow morning."

Step 5: Return Precautions (When to Call / When to Go to the ER)

Write a clear, specific list. Bold the action items:

Call the surgeon's office (during business hours) if you have:

• Temperature of 100.4°F (38°C) or higher
• Increasing redness, swelling, or warmth around the incision
• New drainage from the incision that is cloudy, green, or foul-smelling
• Pain that is getting worse instead of better after the first 3-5 days
• Nausea or vomiting that prevents you from keeping down liquids for more than 24 hours
• No bowel movement for more than 3 days after surgery
• Questions about your medications or wound care

Go to the Emergency Room or call 911 immediately if you have:

• Chest pain, shortness of breath, or difficulty breathing
• Sudden severe abdominal pain
• Heavy bleeding from your incision that does not stop with 10 minutes of firm pressure
• Calf pain or swelling (one leg worse than the other) — this could be a blood clot
• High fever (>101.5°F / 38.6°C) with chills
• Inability to urinate for more than 8 hours
• Signs of allergic reaction to a new medication (hives, difficulty breathing, facial swelling)

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Are activity restrictions specific and measurable (weight limits, driving criteria, return-to-work timeline)?
2. Is the wound care plan procedure-specific (not generic)?
3. Is the medication list complete with plain-language instructions for every discharge medication?
4. Are opioid safety and disposal instructions included?
5. Are return precautions clearly differentiated between "call the office" and "go to the ER"?

Quality Audit

• Discharge instructions written at 5th-8th grade reading level (no medical jargon unexplained)
• Surgeon name and contact information (business hours and after-hours) included
• Follow-up appointment date, time, and location documented
• Activity restrictions are specific with weight limits, timelines, and driving criteria
• Wound care instructions are procedure-specific
• Drain care instructions included (if applicable) with output log provided
• All discharge medications listed with name, dose, frequency, purpose, and duration
• Opioid safety, storage, and disposal instructions included (if opioid prescribed)
• Home medications with restart dates documented
• Diet instructions included (if applicable — especially for GI or bariatric surgery)
• Return precautions include both "call the office" and "go to the ER" categories
• Specific temperature threshold documented (not just "if you have a fever")
• VTE warning signs included (calf pain/swelling, chest pain/SOB)
• Patient/caregiver verbalized understanding (teach-back documented)
• Signed copy provided to patient; copy in the medical record

Guidelines

1. Write at a 5th-8th grade reading level. Use short sentences, common words, and bullet points. Avoid abbreviations and medical terminology without plain-language definitions.
2. Use specific numbers, not ranges or vague terms: "Do not lift more than 10 pounds" not "avoid heavy lifting." "Temperature of 100.4°F" not "if you have a fever."
3. Always include both Fahrenheit and Celsius for temperature thresholds — patients may have different thermometer types.
4. Separate "call the office" return precautions from "go to the ER" return precautions. Patients need to know the urgency level of each symptom.
5. Include VTE warning signs (calf pain/swelling, chest pain/shortness of breath) in every surgical discharge instruction set — PE is a leading cause of post-discharge surgical death.
6. Perform teach-back: Ask the patient or caregiver to explain the key instructions in their own words. Document that teach-back was performed and understanding was confirmed.
7. Provide a printed copy to the patient AND document in the medical record. For patients with limited English proficiency, provide translated instructions or arrange interpreter-assisted discharge education.
8. If the patient is discharged to a skilled nursing facility or with home health, communicate the discharge plan directly to the receiving team in addition to providing written instructions.