Structure, content, unsafe abbreviations, and completeness of discharge summaries: A retrospective analysis in a University Hospital in Austria

Abstract

Rationale and objective The discharge summary (DS) is one of the most important instruments to transmit information to the treating general physician (GP). The objective of this study was to analyse important components of DS, structural characteristics as well as medical and general abbreviations. Method One hundred randomly selected DS from five different clinics were evaluated by five independent reviewers regarding content, structure, abbreviations and conformity to the Austrian Electronic Health Records (ELGA) using a structured case report form. Abbreviations of all 100 DS were extracted. All items were scored on a 4‐point Likert‐type scale ranging from “strongly agree” to “strongly disagree” (or “not relevant”). Subsequently, the results were discussed among reviewers to achieve a consensus decision. Results The mandatory fields, reason for admission and diagnosis at discharge were present in 80% and 98% of DS. The last medication was fully scored in 48% and the recommended medication in 94% of 100 DS. There were significant overall differences among clinics for nine mandatory items. In total, 750 unexplained abbreviations were found in 100 DS. Conclusions In conclusion, DS are often lacking important items. Particularly important are a detailed medication history and recommendations for further medication that should always be listed in each DS. It is thus necessary to design and implement changes that improve the completeness of DS. An important quality improvement can be achieved by avoiding the use of ambiguous abbreviations.

Improving the Quality and Completeness of Discharge Summaries at a Tertiary Care Hospital in Pakistan: A Quality Improvement Project

“…The areas most deficient included patient details, allergy details, concerns and expectations of the patients, and indications of patient involvement. Schwarz et al discovered in their analysis of DS that optional yet important items were often lacking [ 12 ].…”

“…Doctors voiced concerns regarding inaccuracies and omissions in discharge summaries across multiple fields. The information gaps and mistakes that were frequently encountered include changes in medication, pending investigations, referrals, and patient or family counseling/education [2,[12][13][14]. Substantial improvements were observed across various components of the summary during the re-audit conducted after the implementation of interventions.…”

Evaluation of Patient Discharge Information Between What Is Said and What Is Written

“…Continual education, preparation for discharge, and post-discharge monitoring may contribute to enhancing patient satisfaction and reducing adverse effects [6,7,19,20]. [15,16,23,25].…”

A retrospective analysis of discharge summaries from a tertiary care hospital medical oncology unit: To assess compliance with documentation of recommended discharge summary components

“…7 An Austrian retrospective analysis examined the quality of randomly selected discharge summaries and identified quality issues including the absence of important items and frequent use of unexplained abbreviations. 8 …”

“…7 An Austrian retrospective analysis examined the quality of randomly selected discharge summaries and identified quality issues including the absence of important items and frequent use of unexplained abbreviations. 8 Although it has been more than 2 years since the publication of the National Guidelines, to the best of our knowledge, no studies have examined how well discharge summaries adhere to the Australian National Guidelines in any specific sub-speciality.…”