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
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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.
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