Better transitions: improving comprehension of discharge instructions

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This is a first review of the article "Better transitions: improving comprehension of discharge instructions." [1]


In this review article authors have analyzed the effect of health literacy and cognition on the comprehension of hospital discharge instructions. The authors also present how to address the problem of low health literacy and cognition in the hospitalized patients. For patients to be able to provide self-care after discharge, they have to understand the discharge instructions. The discharge instructions may not only be complex but the time given to the patients and caregivers for this task is also relatively short. Due to illness, fatigue, effect of medications patients may not be at their best to understand these instructions. In addition to these factors, health literacy and undiagnosed cognitive dysfunction also is a significant contributor to the understanding of these discharge instructions.

Definitions of Health Literacy And Executive Cognitive Function

Definition of health literacy, in short, is taken form Institute of Medicine (IOM) (2003) and is defined as the ability of a patient to “obtain, process and understand basic health information and services needed to make appropriate health decisions." In 2003 IOM estimated that over 47% of the adults in the US have limited health literacy skills.

Cognition consists of three parts, short-term memory, recall of new information and executive functioning. Executive functioning is the most complex part and depends upon the short-term memory, processing of the new and old information to develop and implement an action plan while understanding the consequences of action or inaction. This article reports that about 30% of the adults over 55 years of age have some form of cognitive dysfunction.

Cognition and Literacy Affect Knowledge Of Discharge Instructions

The authors report that commonly discharge instructions are written at grade 8-13 level, while average patients read at level of grade six. Relatively complex language in discharge instructions, when combined with low health literacy and poor, either recognized or unrecognized, cognition results in poor comprehension of the discharge instructions.


Authors have done a great job in reviewing literature and seeking expert opinion in trying to identify an approach to this problem. A systematic approach of identifying patients with low health literacy and or cognitive problems is recommended. Screening for low health literacy can be done through standardized but simple tests like Short Test of Functional Health Literacy in Adults (STOFHLA), Rapid Estimate of Adult Literacy in Medicine (REALM), and Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) tests. The staff trained in these methods, easily at the bedside, can administer these tests. Similarly tests likes Clock Drawing Test can be used to identify patients with poor cognition. The underlying recommendation is to use a systematic approach to identify these patients, irrespective of the methods employed.

Authors recommend three-tiered approach for improving the comprehension of discharge instructions:

Level I, approach consists of “Universal Precautions” methods by simplifying the discharge instructions for all patients. No one has ever complained that the discharge instructions are two simple. They also recommend that the process be patient centered and to involve the patient’s family or would be caregivers early in the discharge process.

Level II, approach consists of identifying patients with cognitive impairment, adding fields in the EHR’s that can identify these patients easily, by allowing the patients to participate in self-care activities while hospitalized and calling the patients 72 hours after discharge to early identify any problems that may have occurred since discharge.

Level III approach is recommended for the hospitals and systems that have already implemented above two approaches. This consists of employing specifically trained staff for discharge coordination and education, providing post discharge support for high-risk patients.


This is a review article that focuses on improving transition of care by understanding factors that limit comprehension of discharge instructions. A comprehensive approach is required to solve this problem, though EHR’s and electronically created discharge instructions are a step in right direction but are not the complete solution to this problem.


  1. Chugh A, Williams M, Grigsby J, Coleman E. Better Transitions: Improving Comprehension of Discharge Instructions. Frontiers Of Health Services Management [serial online]. Spring2009 2009;25(3):11-32. Available from: Business Source Complete, Ipswich, MA. Accessed November 15, 2015.