Adequacy of Discharge Summaries Prepared by Junior Medical Residents in a University Hospital

Ibrahiem Saeed Abdul-Rahman

doi:doi:10.11648/j.cmr.20120101.11

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Adequacy of Discharge Summaries Prepared by Junior Medical Residents in a University Hospital

Ibrahiem Saeed Abdul-Rahman

Published in Clinical Medicine Research (Volume 1, Issue 1)

Published: 30 December 2012

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Abstract

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.

Published in	Clinical Medicine Research (Volume 1, Issue 1)
DOI	10.11648/j.cmr.20120101.11
Page(s)	1-6
Creative Commons	This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Copyright	Copyright © The Author(s), 2012. Published by Science Publishing Group

Keywords

Discharge Summaries, Medical Residents, Opd, The Joint Commission For Hospital Accreditation

References

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[2]	Standard IM.6.10: Hospital Accreditation Standards. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; 2006:338-340.
[3]	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.
[4]	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.
[5]	Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004; 141:533-536.
[6]	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.
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[8]	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.
[9]	National Quality Forum (NQF). Safe practices for better health care: a consensus report. Washington, DC: NQF, 2003.
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[11]	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.
[12]	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.
[13]	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.
[14]	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.
[15]	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.
[16]	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.
[17]	Bado W, Williams CJ. Usefulness of letters from hospitals to general practitioners. BMJ 1984; 288: 1813-14.
[18]	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.
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APA Style

Ibrahiem Saeed Abdul-Rahman. (2012). Adequacy of Discharge Summaries Prepared by Junior Medical Residents in a University Hospital. Clinical Medicine Research, 1(1), 1-6. https://doi.org/10.11648/j.cmr.20120101.11

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ACS Style

Ibrahiem Saeed Abdul-Rahman. Adequacy of Discharge Summaries Prepared by Junior Medical Residents in a University Hospital. Clin. Med. Res. 2012, 1(1), 1-6. doi: 10.11648/j.cmr.20120101.11

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AMA Style

Ibrahiem Saeed Abdul-Rahman. Adequacy of Discharge Summaries Prepared by Junior Medical Residents in a University Hospital. Clin Med Res. 2012;1(1):1-6. doi: 10.11648/j.cmr.20120101.11

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@article{10.11648/j.cmr.20120101.11,
  author = {Ibrahiem Saeed Abdul-Rahman},
  title = {Adequacy of Discharge Summaries Prepared by Junior Medical Residents in a University Hospital},
  journal = {Clinical Medicine Research},
  volume = {1},
  number = {1},
  pages = {1-6},
  doi = {10.11648/j.cmr.20120101.11},
  url = {https://doi.org/10.11648/j.cmr.20120101.11},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.cmr.20120101.11},
  abstract = {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.},
 year = {2012}
}

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TY  - JOUR
T1  - Adequacy of Discharge Summaries Prepared by Junior Medical Residents in a University Hospital
AU  - Ibrahiem Saeed Abdul-Rahman
Y1  - 2012/12/30
PY  - 2012
N1  - https://doi.org/10.11648/j.cmr.20120101.11
DO  - 10.11648/j.cmr.20120101.11
T2  - Clinical Medicine Research
JF  - Clinical Medicine Research
JO  - Clinical Medicine Research
SP  - 1
EP  - 6
PB  - Science Publishing Group
SN  - 2326-9057
UR  - https://doi.org/10.11648/j.cmr.20120101.11
AB  - 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.
VL  - 1
IS  - 1
ER  -

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Author Information

Ibrahiem Saeed Abdul-Rahman

Department of Internal Medicine, King Fahd Hospital of the University, University of Dammam , Al-Khobar - Saudi Arabia

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APA Style

Ibrahiem Saeed Abdul-Rahman. (2012). Adequacy of Discharge Summaries Prepared by Junior Medical Residents in a University Hospital. Clinical Medicine Research, 1(1), 1-6. https://doi.org/10.11648/j.cmr.20120101.11

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ACS Style

Ibrahiem Saeed Abdul-Rahman. Adequacy of Discharge Summaries Prepared by Junior Medical Residents in a University Hospital. Clin. Med. Res. 2012, 1(1), 1-6. doi: 10.11648/j.cmr.20120101.11

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AMA Style

Ibrahiem Saeed Abdul-Rahman. Adequacy of Discharge Summaries Prepared by Junior Medical Residents in a University Hospital. Clin Med Res. 2012;1(1):1-6. doi: 10.11648/j.cmr.20120101.11

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@article{10.11648/j.cmr.20120101.11,
  author = {Ibrahiem Saeed Abdul-Rahman},
  title = {Adequacy of Discharge Summaries Prepared by Junior Medical Residents in a University Hospital},
  journal = {Clinical Medicine Research},
  volume = {1},
  number = {1},
  pages = {1-6},
  doi = {10.11648/j.cmr.20120101.11},
  url = {https://doi.org/10.11648/j.cmr.20120101.11},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.cmr.20120101.11},
  abstract = {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.},
 year = {2012}
}

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TY  - JOUR
T1  - Adequacy of Discharge Summaries Prepared by Junior Medical Residents in a University Hospital
AU  - Ibrahiem Saeed Abdul-Rahman
Y1  - 2012/12/30
PY  - 2012
N1  - https://doi.org/10.11648/j.cmr.20120101.11
DO  - 10.11648/j.cmr.20120101.11
T2  - Clinical Medicine Research
JF  - Clinical Medicine Research
JO  - Clinical Medicine Research
SP  - 1
EP  - 6
PB  - Science Publishing Group
SN  - 2326-9057
UR  - https://doi.org/10.11648/j.cmr.20120101.11
AB  - 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.
VL  - 1
IS  - 1
ER  -

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