Adequacy of Discharge Summaries Prepared by Junior Medical Residents in a University Hospital
Clinical Medicine Research
Volume 1, Issue 1, December 2012, Pages: 1-6
Received: Nov. 26, 2012;
Published: Dec. 30, 2012
Views 3537 Downloads 124
Ibrahiem Saeed Abdul-Rahman, Department of Internal Medicine, King Fahd Hospital of the University, University of Dammam , Al-Khobar - Saudi Arabia
Discharge summaries are intended to transfer important clinical information from inpatient to outpatient settings and between hospital admissions. Complete, accurate, and timely discharge summaries can communicate important information back to the outpatient (OPD) physician, prevent adverse events and reduce readmission to hospital. However, discharge summaries are not always given the priority it deserves. Too often, discharge summaries contain insufficient or unnecessary information and fail to reach the OPD physician in time for the patient’s follow-up visit. We evaluated dis-charge summaries produced by first-year medical residents (R1) for their completeness and accuracy. Consecutive dis-charge summaries prepared by R1 residents for patients discharged from internal medicine wards were retrospectively eva-luated by two independent reviewers for presence and accuracy of essential items described by the Joint Commission for Hospital Accreditation. One-hundred and thirty-two discharge summaries were assessed for completeness and accuracy. Most items were incompletely reported with a given item missing in 2.3% - 91.7% of all discharge summaries. Inaccuracies of discharge summaries when compared to the patient chart as a reference standard ranged from 8.5% for final diagnosis to 50.9% for anticipated problems and suggested interventions with a mean of 29.6 + 13.3%.Only 18.2% of the discharge summaries were written within 48 hours of patient discharge (p < 0.001). The availability of a finalized (typed and signed) discharge summary at the first post-discharge visit was low (12.1%) and remained poor at 4 weeks (50.8%). Conclusion: Discharge summaries prepared by R1 physicians are grossly inadequate at documenting most of the essential domains described by the Joint Commission for Hospital Accreditation. Our findings will aid in the development of educational interventions for residents.
Ibrahiem Saeed Abdul-Rahman,
Adequacy of Discharge Summaries Prepared by Junior Medical Residents in a University Hospital, Clinical Medicine Research.
Vol. 1, No. 1,
2012, pp. 1-6.
Joint Commission on Accreditation of Healthcare Organization: Hospital national patient safety goals. 2010. www.jcrine.com/. Accessed August 19, 2012.
Standard IM.6.10: Hospital Accreditation Standards. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; 2006:338-340.
Joint Commission on Accreditation of Healthcare Organizations. Joint Commission national patient safety goals. http://www.jointcommission.org/PatientSafety/NationalPatient Safety Goals/. Accessed July 17, 2012.
Rao P, Andrei A, Fried A, Gonzalez D, Shine D. Assessing quality and efficiency of discharge summaries. Am J Med Qual 2005; 20: 337-43.
Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004; 141:533-536.
van Walraven C, Mamdani M, Fang J, Austin P. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004;19:624-631.
Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159-74.
Walraven C, Taljaard M, Bell CM, Etchells E, Stiell JG, Zarnke K, Foster AJ. A prospective cohort study found that provider and information continuity was low after patient discharge from hospital. J Clin Epidemiol 2010; 63: 1000-1010.
National Quality Forum (NQF). Safe practices for better health care: a consensus report. Washington, DC: NQF, 2003.
National Quality Forum (NQF). The National Quality Forum’s consensus development process. Version 1. 7. Washington, DC: NQF, 2004.
Kevin J, O'Leary M, Liebovitz DM, Feinglass J, Liss DT, Evans DB, Kulkarni N, Landler MP, Baker DW. Creating a better discharge summary: improvement in quality and timelines using an electronic discharge summary. Hosp Med 2009; 4: 219-25.
van-Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17:186-92.
Li JY, Yong TY, Hakendorf P, Ben-Tovim D, Thompson CH. Timeliness in discharge summary dissemination is associated with patients' clinical outcomes. J Eval Clin Pract October, 2011; Published online by Blackwell Publishing Ltd. doi:10.111/j.1365-2753.2011.01772.x.
Chen Y, Brennan N, Magrabi F. Is email an effective method for hospital discharge communication? A randomized controlled trial to examine delivery of computer-generated discharge summaries by email, fax, post and patient hand delivery. In J Med Inform 2010; 79: 167-72.
Kripalani S, LeFevre F, Phillips CO, Williams MV, Bassaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007; 297: 831-41.
Wilson S, Ruscoe W, Chapman M, Rhona-Miller RN. General practioners-hospital communications: a review of discharge summaries. J Qual Clin Pract 2001; 21: 104-08.
Bado W, Williams CJ. Usefulness of letters from hospitals to general practitioners. BMJ 1984; 288: 1813-14.
Munday A, Kelly B, Forrester J, Timoney A, McGovern E. Do general practitioners and community pharmacists want information on the reasons for drug therapy changes implemented by secondary care? Br J Gen Pract 1997; 47: 563-66.
Newton J, Eccles M, Hutchinson A. Communication between general practioners and consultants: what should their letters contain? BMJ 1992; 304: 821-24.
Pantilat SZ, Lindenauer PK, Katz PP, Watcher RM. Primary care physicians' attitudes regarding communication with hospitalists. Am J Med 2001; 111: 15S-20S.
van Walraven C, Rokosh E. What is necessary for high quality discharge summaries? Am J Med Qual 1999; 14: 160-69.
Harding J. Study of discharge communications from hospital doctors to an inner London general practice. J R Coll Gen Pract 1987; 37: 494-95.