Quality of discharge summaries prepared by first year internal medicine residents

Abstract

BackgroundPatients are particularly susceptible to medical error during transitions from inpatient to outpatient care. We evaluated discharge summaries produced by incoming postgraduate year 1 (PGY-1) internal medicine residents for their completeness, accuracy, and relevance to family physicians.MethodsConsecutive discharge summaries prepared by PGY-1 residents for patients discharged from internal medicine wards were retrospectively evaluated by two independent reviewers for presence and accuracy of essential domains described by the Joint Commission for Hospital Accreditation. Family physicians rated the relevance of a separate sample of discharge summaries on domains that family physicians deemed important in previous studies.ResultsNinety discharge summaries were assessed for completeness and accuracy. Most items were completely reported with a given item missing in 5% of summaries or fewer, with the exception of the reason for medication changes, which was missing in 15.9% of summaries. Discharge medication lists, medication changes, and the reason for medication changes—when present—were inaccurate in 35.7%, 29.5%, and 37.7% of summaries, respectively. Twenty-one family physicians reviewed 68 discharge summaries. Communication of follow-up plans for further investigations was the most frequently identified area for improvement with 27.7% of summaries rated as insufficient.ConclusionsThis study found that medication details were frequently omitted or inaccurate, and that family physicians identified lack of clarity about follow-up plans regarding further investigations and visits to other consultants as the areas requiring the most improvement. Our findings will aid in the development of educational interventions for residents.

Optimizing the quality of hospital discharge summaries – a systematic review and practical tools

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Hospital discharge summary scorecard: a quality improvement tool used in a tertiary hospital general medicine service

“…In most hospitals, interns are responsible for completing the majority of discharge summaries but who have received little or no prior training or experience in this task . Not surprisingly, studies have shown that discharge summaries prepared by interns contain more errors and lack clarity compared with those completed by more experienced registrars and consultants …”

Assessing Origins of Quality Gaps in Discharge Summaries: A Survey of Resident Physician Attitudes

“…Discharge summaries are a prime example. Research has identified several flaws with current discharge summaries; outpatient practitioners are dissatisfied with the quality [1], and medication reconciliation errors may lead to readmission [2]. Although there have been many efforts to improve authorship of discharge summaries [3-10], little is known about the attitudes of the primary authors of these documents at academic institutions, namely interns, residents, and physician assistants (PAs).…”