If you are reading this journal, you are probably interested in endoscopy procedures. We (nurses) see people who are going to have them, prepare the patient for them, assist with them, admit and discharge patients from them, and follow up after these procedures have been done. All procedures have important elements: admission and consent, the actual procedure, recovery, and discharge. In this column, I want to reflect on the discharge instructions. I hadn't given this much thought until my local regional hosted a seminar and had a speaker who was an endoscopy nurse and attorney. Her discussion and the questions that ensued gave me some interesting perspectives that I hadn't previously thought about.

In the past (when I used to assist with procedures), the procedure was completed, the patient recovered, the discharge instructions were given to the patient, and the patient was sent on his or her way. Sometimes the patient had a family member or friend with him or her during the discharge instructions, but at other times, that person went ahead of the patient to get the car while the instructions were presented to the patient. Can a patient who has been sedated be held responsible or accountable for information on the discharge instructions?

If the nurse tells the patient that he or she should not drive a car or operate machinery for the rest of the day and he or she signs the discharge instructions, what happens when the patient goes home and mows the lawn and runs over his or her foot with the lawnmower? We understand that consent would not be valid if it was signed after receiving sedating drugs or narcotics. Therefore, wouldn't it stand to reason that the consent is meaningless if it is signed by someone who has been sedated for a procedure? Is the consent necessarily a legal document? If the driver is not a family member, can he or she sign it? If so, what validity would that have? If there was a problem and records were pulled for a court case, wouldn't they be included?

During the discussion that ensued after the presentation, there were some interesting points. Many practices are going to electronic medical records (EMRs). Some people participating in the discussion noted that their systems are "click" systems and that there are no patient signatures. Documentation is just a check in a box that reflects something was done. Another click, and a page can be printed out.

I think most discharge plans cover such key instructions as the following:

* Don't drive or operate machinery the day of the procedure.

* Don't make any important legal decisions.

* Contact your care provider if you develop problems after your procedure such as fever, severe pain, severe nausea or vomiting, or bleeding.

Sometimes there is an area in the EMR to add additional instructions about medications, pathology, or further testing. The EMRs that I have seen are printed with the patient's name and a place for the nurse's signature, the patient's signature, and the physician's signature. The physician's signature is electronic, however, and is added to the EMR after the procedure report is generated. Our office receives only a copy of the EMR record, so the patient and nurse signatures are therefore not included. I would like to think that all signatures are present when the patient is discharged and put in the patient's file in the endoscopy center-but are they?

I have heard of other institutions that actually review the routine discharge instructions (e.g., not driving, potential complications) with the patient prior to the procedure. The patient signs, confirming that instructions were provided, and/ or the nurse documents the education in the EMR. Additional education that follows the procedure often includes further directions for taking medications, additional required testing, procedure results, and follow-up. Because this education is given at a separate time from the preprocedure education, should it be documented separately?

No system is fool proof. I have had patients lose a prescription or lab order going from the office to the pharmacy or lab, which is in the same building. I'm sure that there are patients who have lost a discharge paper going from the endoscopy center to home. We also verbally tell patients many things. With the sedation we give patients for procedures, most patients won't remember what we've said. Having the patient's postprocedure driver present at discharge would provide someone who might be able to help reinforce important postprocedure care. In addition, many patients are overwhelmed and may not remember well or, when given a lot of information at one time, can only retain a limited amount.

Is there a legal obligation associated with discharge instructions? If we have instructed the patient not to drive, but he or she does drive and is injured or causes injury to someone else, are we liable? Are we "less" liable if we verbally instructed the patient, if we gave him or her a printed sheet of instructions, or if he or she has signed a sheet that says that he or she has been informed that he or she should not drive? Is the instruction more valid before the procedure/ medications than it is after? If discharge instructions are given after the procedure and the patient had been sedated, is it valid if someone else signs instead of the patient?

If the patient undergoes a procedure and has concerning pathology, whose responsibility is it to ensure they get follow-up treatment? For example, the patient has an area in his or her esophagus with some dysplasia and the endoscopist wants to recheck the area in 6 months. Is it the patient's responsibility to contact the office to schedule follow-up treatment? Or does the endoscopy center contact the endoscopist's office to schedule follow-up treatment for the patient? Will the endoscopist's office actually contact the patient to schedule follow-up treatment?

Many patients mistakenly make the assumption that if findings are abnormal, someone will contact them. Unfortunately, we all know of cases in which responsibilities have been neglected and no one calls the patient because the patient had been told to call the office to go over pathology results. Do endoscopy units contact patients routinely after procedures to determine whether there were any questions or problems? Do offices have a way of monitoring procedures with pathology to make sure follow-up treatment is initiated?

I have many questions regarding these aspects of care, but I do feel "more is better" when it comes to legal issues. Be sure to review discharge concerns with patients prior to them being sedated. Talk with patients and their drivers (if the patient permits), and give written information and follow-up instructions. No system is fool proof, but we want to do the best we can to protect the patient, ourselves, our facilities, and the public.