Assessing quality and efficiency of discharge summaries

Am J Med Qual. Nov-Dec 2005;20(6):337-43. doi: 10.1177/1062860605281078.

Abstract

Discharge summaries are intended to transfer important clinical information from inpatient to outpatient settings and between hospital admissions. The authors created a point scale that rated summaries in 4 key areas and applied the scale at a community teaching hospital over 3 years. Charts of 150 patients were selected equally from those discharged early and late in the academic year. Residents dictated all summaries after July 2003 using a prominently displayed template. Two residents and a senior physician assessed dictation quality. Considerable differences were found among raters, particularly in the evaluation of style. The average of the 3 raters' scores improved 21%, and dictation length decreased 67% after introduction of the template (P < .001). No relationship was found among service intensity (measured as chart weight), dictation length (measured in lines), and quality. Measured by a comprehensive rating scale, the quality of discharge summaries increased with use of a template while their length decreased.

MeSH terms

  • Continuity of Patient Care*
  • Efficiency, Organizational
  • Forms and Records Control
  • Hospitals, Community / standards*
  • Hospitals, Teaching / standards*
  • Humans
  • Medical Records / standards*
  • New Jersey
  • Observer Variation
  • Patient Discharge*
  • Quality Assurance, Health Care / methods*