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

Abstract

Introduction: 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). Methods: 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. Results: The workshop was well received by residents and median scores on the rubric improved from 39 to 45 (p < .001) postworkshop. Discussion: 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.

Improving Resident Hospital Discharge Communication by Changing Electronic Health Record Templates to Enhance Primary Care Provider Satisfaction

“…Prior studies were limited by their use of resident educational curricula to improve discharge summaries; however, the EHR template described here uses repeated, system-level reinforcement embedded into the workflow to train residents on care transition priorities. [27][28][29] The 8-item template (Figure 2) addresses common discharge summary deficiencies reported in previous studies and confirmed in our focus groups. 6,15 Each item was created in response to PCP feedback: some items steer writers from common pitfalls, such as reporting the chief complaint as the main diagnosis; some prompt rationale to prevent future adverse events, such as fields for medication changes and "why"; some remind providers of diagnostic tests during hospitalization, such as incidental findings or pending results; and some elicit thoughtful recommendations for postdischarge providers, such as instructions from consultants or the inpatient team.…”

“…Continuously emphasizing important discharge elements and breaking down barriers in care transitions during residency training are key to this work. Prior studies were limited by their use of resident educational curricula to improve discharge summaries; however, the EHR template described here uses repeated, system-level reinforcement embedded into the workflow to train residents on care transition priorities 27-29. The 8-item template (Figure 2) addresses common discharge summary deficiencies reported in previous studies and confirmed in our focus groups 6,15.…”

Lack of recognition and documentation of stress hyperglycemia is a disruptor of optimal continuity of care

“…The ACGME reinforces this idea by requiring competency in many milestones, including appropriate utilization and completion of health records (ICS3) milestone 50 . Several institutions have developed quality improvement projects to improve the standards and timeliness of discharge summaries, resulting in statistically significant improvements of multiple domains 51 – 53 . Academic and community medical institutions should consider adopting continuing medical education programs into their curriculum to promote more accurate and timely discharge summaries.…”

A Quality Improvement Approach to Improving Discharge Documentation

“…18,19 Additionally, scheduling follow-up appointments before discharge leads to increased primary care follow-up and potentially decreased readmission rate. 20 Previous studies have demonstrated improvement in the completion and quality of discharge summaries following educational interventions targeted toward medical trainees, 14,15,[21][22][23] and some have utilized quality improvement (QI) methodology. 6,24,25 However, few studies have demonstrated a sustainable change in pediatric settings in the era of electronic health record (EHR) use.…”