Discharge Summaries: A Neglected Education in Residency Program in Iran

Abstract

Discharge summary (DS) is an essential document in patients’ medical records, and its information is critical during the care of patients. So, inaccurate DS increases the risk of medical errors (1, 2). In teaching hospitals with residency programs, residents are usually responsible for writing DSs. Failure to pay attention to the education of writing and creating DS in the curriculum of medicine leads residents to be unfamiliar with the requirements and contents of DSs. However, there is no national instructions or guidelines for creating a complete and accurate DS. Lack of teaching to residents on how to write a DS is the gap in medical education and may jeopardize the continuity of care. A preliminary study on hospital DSs at Golestan University of Medical Sciences (GoUMS) revealed the fact that the quality of the DSs was not appropriate in terms of accuracy and completeness. To overcome this defect, the Internal Medicine Department at GoUMS has developed a program called the “Discharge Conference” for the residents of Internal Medicine. The purpose of “Discharge Conference” is to review the DSs and to teach how to record and document it properly. Contrary to the morning reports, in which the cases of previous nights are surveyed, at the “Discharge Conference”, the patients’ DSs recorded by residents are reviewed, critically. From September 2017, the “Discharge Conference” has been held on the first Sunday of each month for about 2 hours. In addition to all residents of Internal Medicine, medical interns also attend the conference. Under the supervision of an attending professor, the DSs are presented by the second year Internal Medicine residents. In each conference, summaries of the discharged patients from Internal Medicine wards (nephrology, rheumatology, endocrinology, gastroenterology, hematology, and pulmonary) are selected, reviewed, and scrutinized, and the requirements of a good DS are taught. After one year of implementing the program, the evaluation of the results showed that the quality of DSs has increased significantly and this program enhances the residents’ skills to write and create a complete and accurate DS. Several studies have shown that teaching how to write a discharge summary increases the quality of DSs and the recording skills of residents (1, 3, 4). Therefore, DS curriculum is essential to be included in medical education program, and the lack of appropriate training program in this field can lead to adverse events and increase medical errors. In conclusion, if “Discharge Conference” takes place on a planned, targeted, and regular basis, it will be an appropriate educational program for training residents on how to write DSs. It is suggested that “Discharge Conference” be considered as a part of the residency programs.Conflict of Interest: None Declared.