Quality Of Discharge Summaries Research Articles

Improving the quality of electronic discharge summaries from medical wards: A quality improvement project

The electronic discharge (e-discharge) summary forms an essential component of communication between secondary and primary care. However, its content and quality can often be substandard due to inadequate or inaccurate information. Two retrospective audits were completed with intervening e-discharge workshops. Local general practitioners were involved in identifying areas for improvement and assisted with the workshops. Crib sheets were emailed to all junior staff and posted on all medical wards. There was an improvement in the quality of e-discharges with particular improvements on the documentation of test results and patient progress and outcome. Those who attended the workshops produced better quality e-discharges and none recommended unnecessary actions for general practitioners. E-discharge workshops are effective in improving the overall quality of discharge summaries from medical wards. Introduction of mandatory e-discharge training sessions during hospital induction and junior doctor rotations would be beneficial to teach this important yet challenging skill.

Medication Error and Interprofessional Communication-Related Factors Contributing to Hospitalisation in Community-Dwelling Older Adults in Australia

Background: Population ageing is a worldwide phenomenon. It is common for older adults to develop multiple age-related illnesses and the prevalence of multimorbidity increases substantially with age. Multimorbid adults are frequently treated with several concurrent medications and the regimen may be complex requiring multiple steps in the preparation of a medication prior to its administration. Polypharmacy is a concerning trend and older adults have a 100% risk of experiencing adverse drug events when taking ten or more medications concurrently. Discharge summaries communicating the number of medications, changes made to medication regimens during hospitalisations and the requirement for ongoing monitoring in the community are often incomplete. The aim of this study was to investigate contributing factors to medication-related hospitalisation, length of stay or readmission in older community-dwelling persons and examine the quality of discharge summaries. Methods: Descriptive and correlational analyses of demographic, clinical, admission, readmission, length of stay and medication variables were examined in Australia in 2016-2018. Discharge summaries were analysed for completeness, timeliness and interprofessional communication. Results: There were 295 participants, mean age 80 years, 55% were female, taking an average of 11 prescribed medications and with a mean Medication Regimen Complexity Index score of 34. Medication errors that were unrecognised at the time of hospitalisation were present in 19% of the sample. Factors associated with medication error were older age and a longer median length of stay. Fewer than 52% of these older patients had detailed discharge summaries. Conclusion: The prevalence of polypharmacy and medication regimen complexity at admission was high. A high proportion of older adults on medical units may have unrecognised medication errors impacting their admission. Medical discharge summaries are inadequately addressing this issue for patients returning to the care of their family physician.

An Evaluation of the Content of Pediatric Discharge Summaries.

The need for high-quality discharge summaries is critical to ensure safe transitions of care. Deficits may lead to lapses in communication and poor outcomes. In this study, we sought to characterize the completeness, accuracy, and quality of pediatric discharge summaries. A retrospective chart review of 200 discharge summaries of patients discharged from the general pediatrics service from July 2016 to October 2017 was conducted. These summaries were audited for 7 elements: admission date, discharge date, discharge diagnosis, medications, immunizations, pending laboratory tests, and follow-up appointments. Accuracy was verified through chart review. Quality of hospital course and patient instructions was evaluated by using a modified validated discharge summary evaluation tool. Additional data collected included medical complexity of the patient and the number of authors. Analysis of variance, χ2 tests, and Pearson correlations were used to analyze data. Discharge diagnosis, medications, and follow-up appointments had the lowest rates of completion and accuracy. The quality of the hospital course and patient instructions was variable, with no statistical significance seen in quality scores on the basis of the number of authors or medical complexity. There were more inaccuracies in discharge medications for patients with baseline chronic conditions than those without chronic conditions (63% vs 35%; P < .001). Content and quality of discharge summary documentation are inconsistent and have implications for patient outcomes after discharge. This study highlights areas of opportunity to improve pediatric discharge summaries. Future work should be focused on educational and systems-based interventions to improve documentation.

Discharge Communication Practices for Children With Medical Complexity: A Retrospective Chart Review.

Children with medical complexity (CMC) have an increased risk of adverse events after hospital discharge. Authors of previous studies have evaluated discharge communication practices with primary care providers (PCPs) in adults and general pediatric patients. There is a lack of evidence surrounding hospitalist communication practices at discharge for CMC. In this study, we explore hospitalist-to-PCP communication for CMC at hospital discharge. A retrospective chart review was performed at a single tertiary care children's hospital. The population included patients with ≥1 complex chronic condition who were discharged from the pediatric hospitalist team. The presence, type, and quality of discharge communication were collected. A descriptive analysis in which we used χ2, t test, Wilcoxon rank testing, and odds ratios was conducted to identify differences in communication practices in CMC. We identified 368 eligible patients and reviewed their electronic medical records. Discharge communication was documented for 59% of patient encounters. Communication was less likely to occur for patients with technology dependence (P = .01), older patients (P = .02), and those who were admitted to a teaching service (P = .04). The quality of discharge summaries did not change for patients with technology dependence compared with patients without technology dependence. Communication with the PCP at discharge was less likely to be documented in children with technology dependence. Hospitalists may encounter barriers in completion of appropriate and timely discharge communication with PCPs for CMC. Consistent handoff processes could be used to improve care for our patients with enhanced coordination needs.

An evaluation of educational interventions aimed at preparing medical students for discharge summary writing: a rapid review of the literature

Whilst discharge summaries are important for ensuring patient continuity of care, they often lack important information. Medical students and newly qualified doctors have attributed this to insufficient teaching, thereby indicating a need to improve discharge summary education within the undergraduate medical curriculum. The aim was to review educational approaches used to prepare undergraduate medical students for discharge summary writing, and their effectiveness Medline and Scopus were systematically searched using keywords, for studies published between 2009 and 2019. Narrative synthesis was used to integrate the findings of the included studies. Study quality was appraised using the Medical Education Research Study Quality Instrument. Six studies were included in this review. Allowing students to write a discharge summary following a real patient encounter and receive written feedback was the most common educational approach used (n = 4). Three of these studies improved student attitudes towards discharge summary writing. One study described the use of a mobile application, which improved discharge summary quality. Another study utilized interprofessional learning but the effect was statistically insignificant. Medical Education Research Study Quality Instrument scores were satisfactory (mean = 12, range = 8.4-15). The literature concerning this topic is limited. The results indicate that providing written feedback to students can positively influence attitudes towards discharge summary writing. Optimisation of the quality of discharge summaries written by medical students using feedback and checklists requires further investigation, as does the use of interprofessional learning. Future studies would additionally benefit from including participant baseline data and control groups, being multicentred and measuring behavioural or patient/healthcare outcomes.

Machine Learning Based Sentiment Text Classification for Evaluating Treatment Quality of Discharge Summary

Patients’ discharge summaries (documents) are health sensors that are used for measuring the quality of treatment in medical centers. However, extracting information automatically from discharge summaries with unstructured natural language is considered challenging. These kinds of documents include various aspects of patient information that could be used to test the treatment quality for improving medical-related decisions. One of the significant techniques in literature for discharge summaries classification is feature extraction techniques from the domain of natural language processing on text data. We propose a novel sentiment analysis method for discharge summaries classification that relies on vector space models, statistical methods, association rule, and extreme learning machine autoencoder (ELM-AE). Our novel hybrid model is based on statistical methods that build the lexicon in a domain related to health and medical records. Meanwhile, our method examines treatment quality based on an idea inspired by sentiment analysis. Experiments prove that our proposed method obtains a higher F1 value of 0.89 with good TPR (True Positive Rate) and FPR (False Positive Rate) values compared with various well-known state-of-the-art methods with different size of training and testing datasets. The results also prove that our method provides a flexible and effective technique to examine treatment quality based on positive, negative, and neutral terms for sentence-level in each discharge summary.

Accuracy of pharmacist electronic discharge medicines review information transmitted to primary care at discharge.

Background The poor quality of discharge summaries following admission to hospital, especially in relation to information on medication changes, is well documented. Hospital pharmacists can record changes to medications in the electronic discharge note to improve the quality of this information for primary care. Objective To audit the pharmacist-completed notes describing changes to admission medication, and to identify improvement opportunities. Setting 750-bed teaching district general hospital in England. Methods An evaluation of pharmacist written notes was conducted at a 750-bed teaching district general hospital in England. A sample of notes was analysed in three consecutive years, 2016-2018. Analyses were performed using descriptive statistics. Main outcome measure The number of discrepancies in the note compared to the discharge summary medication list. Results Notes were analysed for 125, 120 and 120 patients in 2016-2018 respectively. We saw an overall improvement in the accuracy of our notes from 12% of patients having an inaccurate note in 2016 to 4.2% in 2017 and 5.8% in 2018. The percentage of discharge medicines affected by these discrepancies reduced from 1.7% (2016) to 0.6% (2017) and 0.9% (2018). Conclusion Discrepancies were due to changes in the patient's medicines journey not being fully captured and documented. The overall reduction of discrepancies over the three consecutive audits was felt to be largely due to formalisation of the discharge medicines reconciliation process and reminding staff on how to complete a note. We are planning to utilise informatics surveillance tools along with system developments to sustain this elimination of out of date notes being transmitted to primary care.

A novel curriculum to train physician assistant students how to write effective discharge summaries

ABSTRACTBackground: Physician assistants (PAs) are an integral part of inpatient care teams, but many PAs do not receive formal education on authoring discharge summaries. High-quality discharge summaries can mitigate patient risk during transitions of care by improving inter-provider communication.Objective: To understand the current state of discharge summary education at our institution, and describe a novel curriculum to teach PA students to write effective discharge summaries.Design: Students completed a pre-survey to assess both knowledge and comfort levels regarding discharge summaries. They wrote a discharge summary and received feedback from two evaluators, an inpatient provider (IPP) familiar with the described patient and a simulated primary care provider (PCP). Students completed a post-survey reassessing knowledge and comfort.Results: Prior to instituting this curriculum, the majority of students (92.9%) reported rarely or never receiving feedback on discharge summaries. Eighty-four of 88 (95.5%) eligible students participated. There was discordance between IPP and simulated PCP feedback on their assessment of the quality of discharge summaries; simulated PCPs gave significantly lower global quality ratings (7.9 versus 8.5 out of 10, p = 0.006). Key elements were missing from >10% of discharge summaries. Student response was favorable.Conclusion: Clinically relevant deficiencies were common in students’ discharge summaries, highlighting the need for earlier, structured training. IPPs and simulated PCPs gave discordant feedback, emphasizing differing needs of different providers during transitions of care. This novel curriculum improved students’ knowledge and confidence.

An evaluation of the quality of discharge summaries from the general paediatric wards at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.

Hospital discharge summaries are deemed to be an essential part of the medical record in South Africa, but formal assessment of their quality is rarely undertaken. At Chris Hani Baragwanath Academic Hospital (CHBAH) in Johannesburg, medical admission notes (bedletters) are difficult to retrieve from the hospital archives and the discharge summary is often the only readily available medical record that documents details of the hospital admission. To determine the proportion of discharge summaries that were appropriately completed for children admitted to the general paediatric wards at CHBAH. A retrospective review of discharge summaries completed for children admitted from 1 May to 31 July 2016 was undertaken. The completeness of the following demographic and clinical variables was assessed: patient identifiers, hospital outcome, HIV infection status and anthropometric status. The documentation of correct International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) codes was assessed in children diagnosed with any form of lower respiratory tract infection (LRTI), which is the commonest diagnosis recorded in hospitalised children at CHBAH. Discharge summaries were available for 1 148 (78.3%) of 1 466 children admitted during the study period. For completed discharge summaries, 80.1 - 93.3% of patient identifiers and 91.4% of patient outcomes were appropriately completed. HIV exposure was documented in 84.7% of summaries. Anthropometric parameters, including weight and length/height at admission and discharge weight, were appropriately completed in 91.4%, 70.9% and 50.0% of summaries, respectively. The ICD-10 code for children with LRTI was appropriately recorded by medical staff in 338 (67.2%) of 503 cases. ICD‑10 codes and anthropometric parameters, which are important clinical parameters in the paediatric follow-up consultation, were both correctly recorded for only 21.6% of children who required follow-up clinical consultations at CHBAH. Compared with similar studies, both the rate of completion and the quality of completed discharge summaries were modest in this tertiary academic teaching hospital. As discharge summaries are crucial medical documents, interventions to improve their completeness rate and quality need to be developed.

Level of accuracy of diagnoses recorded in discharge summaries: A cohort study in three respiratory wards.

One of the key functions of the discharge summary is to convey accurate diagnostic description of patients. Inaccurate or missing diagnoses may result in a false clinical picture, inappropriate management, poor quality of care, and a higher risk of re-admission. While several studies have investigated the presence or absence of diagnoses within discharge summaries, there are very few published studies assessing the accuracy of these diagnoses. The aim of this study was to measure the accuracy of diagnoses recorded in sample summaries, and to determine if it was correlated with the type of diagnoses (eg, "respiratory" diagnoses), the number of diagnoses, or the length of patient stay. A prospective cohort study was conducted in three respiratory wards in a large UK NHS Teaching Hospital. We determined the reference list of diagnoses (the closest to the true state of the patient based on consultant knowledge, patient records, and laboratory investigations) for comparison with the diagnoses recorded in a discharge summary. To enable objective comparison, all patient diagnoses were encoded using a standardized terminology (ICD-10). Inaccuracy of the primary diagnosis alone and all diagnoses in discharge summaries was measured and then correlated with type of diseases, number of diagnoses, and length of patient stay. A total of 107 of 110 consecutive discharge summaries were analysed. The mean inaccuracy rate per discharge summary was 55% [95% CI 52 to 58%]. Primary diagnoses were wrong, inaccurate, missing, or mis-recorded as a secondary diagnosis in half the summaries. The inaccuracy rate was correlated with the type of disease but not with number of diagnoses nor length of patient stay. Our study showed that diagnoses were not accurately recorded in discharge summaries, highlighting the need to measure and improve discharge summary quality.

Discharge Summaries: A Neglected Education in Residency Program in Iran

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.

Impact of Educational Intervention on Quality of Discharge Summaries

Impact of Educational Intervention on Quality of Discharge Summaries

Development of a quality scoring tool to assess quality of discharge summaries.

Introduction:Timely, precise, and relevant communication between hospital-based clinicians and primary care physicians post-discharge (DC) ensures quality transitions, thereby reducing patient safety incidents and preventing readmission. At the present time there is limited knowledge of elements of quality or methods to score the quality criteria in the context of DC summaries. The Nova Scotia Health Authority, a provincial health system responsible for the delivery of services in a small Canadian province, embarked on a system-level approach to the standardization of DC summaries in an effort to improve quality and safety at care transitions from hospital to primary care.Materials and Methods:A comprehensive literature review to retrieve items relevant to quality in DC summaries, retrospective audit of charts, a consensus development process, and, finally, validation of a scoring tool were conducted in order to develop a quality scoring tool for DC summaries.Results:Relevant items were identified through the literature review and consensus development process. Corresponding definitions that were established assisted the development of the quality criteria, which were subsequently used to score the quality of DC summaries in our organization.Conclusion:The scoring tool developed through this work will be applied to help us gain a more in-depth understanding of quality in DC summaries and support the development of suitable education and quality processes in the health authority that can best support safe care transitions for patients.

A randomised controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death or hospital readmission

ObjectiveTo assess the efficacy of an electronic discharge communication tool (e-DCT) for preventing death or hospital readmission, as well as reducing patient-reported adverse events after hospital discharge. The e-DCT assessed...

Transitions of Care: Improving the Quality of Discharge Summaries Completed By Internal Medicine Residents.

Discharge summaries are now the accepted means of communication in transition from inpatient to ambulatory care. However, there is often no formal residency education on this critical document, leading to discordance in discharge summaries written by internal medicine residents. There is little in the literature focusing on teaching how to effectively create a discharge summary using an electronic health record (EHR). A 1-hour workshop was designed to teach components of the discharge summary and how to utilize this document to safely transition patients from the inpatient to the ambulatory setting. One or two faculty facilitators led the workshop with approximately 20 resident learners. A 50-point rubric was created to assess effectiveness of discharge summaries pre- and postworkshop. The workshop was well received by residents and median scores on the rubric improved from 39 to 45 (p < .001) postworkshop. We found that by teaching the concepts using examples of discharge summaries written by our residents, and then creating a standardized EHR template, residents wrote more effective discharge summaries with increased focus on the transition to the ambulatory provider. These materials can be applied to other programs and levels of learners to improve discharge summary quality. This serves to provide a resource to those at other institutions looking to create a more formalized didactic session on discharge summaries with a particular focus on transitioning care to the ambulatory provider.

Design and Hospitalwide Implementation of a Standardized Discharge Summary in an Electronic Health Record

The hospital discharge summary is the primary method used to communicate a patient's plan of care to the next provider(s). Despite the existence of regulations and guidelines outlining the optimal content for the discharge summary and its importance in facilitating an effective transition to posthospital care, incomplete discharge summaries remain a common problem that may contribute to poor posthospital outcomes. Electronic health records (EHRs) are regularly used as a platform on which standardization of content and format can be implemented. The feasibility of designing and implementing a standardized discharge summary hospitalwide using an EHR was examined-to the authors' knowledge, for the first time. This large-scale project at the University of Wisconsin Hospital and Clinics was led by a task force that had been assembled to develop best practices for EHR notes. The evidence-based Replicating Effective Programs (REP) model was employed to guide the development and implementation during the project. REP outlines four stages in clinical health service intervention implementation: preconditions, preimplementation, implementation, and maintenance. At 18 months postimplementation, 90% of all hospital discharge summaries were written using the standardized format. Hospital providers found the template helpful and easy to use, and recipient providers perceived an improvement in the quality of discharge summaries compared to those previously sent from the hospital. Discharge summaries can be standardized and implemented hospitalwide with both author and recipient provider satisfaction, particularly if evidence-based implementation strategies are employed. The use of EHR tools to guide clinicians in writing comprehensive discharge summaries holds promise in improving the existing deficits in communication at transitions of care.

Design of an orthopaedic-specific discharge summary.

BackgroundPatients undergoing orthopaedic procedures experience major changes in function and daily routines upon their return home. Discharge summaries are an important communication tool that may play a role in optimizing a safe transition from hospital. Current care gaps and key elements of an ideal discharge summary specific for orthopaedic population are unknown. We sought to identify the challenges of current orthopaedic discharge summaries and to determine key elements of an ideal document.MethodsQualitative study survey using semi-structured interviews with a sample of 17 patients and clinicians representing diverse professions, backgrounds, and practice settings. We used the constant comparative method of qualitative analysis to define the experiences and perceptions of quality gaps and strategies to improve orthopaedic-specific discharge summaries.ResultsWe identified 3 major themes describing factors perceived to be limiting the quality of current discharge summaries: 1) physician-centric documentation and the absence of a comprehensive, inter-professional perspective; 2) access to resources and health informatics; and 3) process variations in document creation and dissemination.ConclusionsClinicians and patients identified several factors limiting the quality of discharge summaries among orthopaedic inpatients. Incorporating these elements could improve hospital transitions.

Competencies for Patient Safety and Quality Improvement

The hospital discharge summary is the primary method used to communicate a patient’s plan of care to the next provider(s). Despite the existence of regulations and guidelines outlining the optimal content for the discharge summary and its importance in facilitating an effective transition to posthospital care, incomplete discharge summaries remain a common problem that may contribute to poor posthospital outcomes. Electronic health records (EHRs) are regularly used as a platform on which standardization of content and format can be implemented. The feasibility of designing and implementing a standardized discharge summary hospitalwide using an EHR was examined—to the authors’ knowledge, for the first time.This large-scale project at the University of Wisconsin Hospital and Clinics was led by a task force that had been assembled to develop best practices for EHR notes. The evidence-based Replicating Effective Programs (REP) model was employed to guide the development and implementation during the project. REP outlines four stages in clinical health service intervention implementation: preconditions, preimplementation, implementation, and maintenance.At 18 months postimplementation, 90% of all hospital discharge summaries were written using the standardized format. Hospital providers found the template helpful and easy to use, and recipient providers perceived an improvement in the quality of discharge summaries compared to those previously sent from the hospital.Discharge summaries can be standardized and implemented hospitalwide with both author and recipient provider satisfaction, particularly if evidence-based implementation strategies are employed. The use of EHR tools to guide clinicians in writing comprehensive discharge summaries holds promise in improving the existing deficits in communication at transitions of care.

The effect of the Shorter Stays in Emergency Departments health target on the quality of ED discharge summaries

ObjectiveTime targets for ED stays are used as a policy instrument to reduce ED crowding. There is debate whether such policies are helpful or harmful, as focus on a process...

Discharge documentation improvement project: a pilot study.

Discharge summaries remain a critical communication tool with primary care physicians. In a previous study of over 200 general medicine discharge summaries, we demonstrated that only 50% contain information regarding the indication and follow up required of any medicine changes on discharge. In this follow up pilot study, we assess the role of feedback and token incentives in improving discharge documentation. Over a 14-week period, we randomly audited a selection of discharge summaries on a fortnightly basis. The results of these audits were fed back to the junior medical staff who compiled these summaries. If over 80% of the audited discharge summaries adequately documented the indication, with required follow up for new medication changes, junior doctors were provided with a token, non-monetary incentive for their efforts. At the end of the study period, we then conducted a survey of the junior doctors involved and collected feedback regarding their impressions of the study. Over the study period, 722 discharge summaries were completed and eligible for analysis. Over this time, mean appropriate documentation regarding medicine indication improved by 32%, and follow-up documentation improved by 10%. Overall, the participants felt the interventions were beneficial and that they should be continued beyond the study period. Education coupled with regular feedback and non-monetary incentives can potentially lead to improvements in the quality of discharge summaries.